COVID in the Street of Boston, Episode 3: Boston Hope

Barry Bock: In April, 2020, Boston Health Care for the Homeless Program was scrambling to keep our patients safe from COVID, which was spiking nationwide. Everyone in our program was working nonstop, and we had managed to create two isolation facilities: the tents that we had talked about in episode one, and our Barbara McInnis House respite facility, which we had talked about in episode two. But the pandemic was obviously showing no signs of slowing down, and our city was running out of space to isolate patients who were living in shelters and on the streets.

The city and state had asked Boston Health Care for the Homeless Program to work with Boston Medical Center, our largest partner to open a field hospital. We were working on that when a call came in from the mayor's office. They wanted us to help set up and operate a different site that would be called Boston Hope. They explained that it was going to be a thousand-bed field hospital built inside the gigantic and empty Boston Convention Center. We would need to set up and manage 500 beds for our patients who were COVID positive and Mass General Brigham would manage the other 500 patients.

This was huge. This was, in fact, overwhelming. As you know, it was a time when the hospitals in Massachusetts were overwhelmed, the shelters were overwhelmed, and we were overwhelmed already. So first of all, I was so grateful that Boston Medical Center took on the opening of their 200-bed field hospital without us. We were feeling stretched but excited that between Boston Medical Center, Mass General Brigham, and Boston Health Care for the Homeless Program, we would be adding over 1200 additional beds to care for patients who were COVID positive.

We needed a team to run Boston Hope. We needed people who were tough and smart, and who could work a hundred hours a week for weeks on end, and who had the organizational skills to pull off this incredible task. So our leadership team—Barb, April, Jesse and Denise—got together and decided that we would ask two people to operate this site. The first was Peter Smith, a primary care physician on our team and the medical director of our largest outpatient clinic.

Peter Smith: I started working at Health Care for the Homeless around 2016. I had previously worked at another community health center in Boston and moved here because I was really interested in working with this population and I was really interested in addiction medicine.

Barry Bock: Peter is a brilliant physician, really gifted. A total rockstar. He has a great sense of humor, is humble, and is exceptional clinically. The other person we asked was Bridget Sullivan, a superstar nurse and our nurse educator who helped to set up the COVID unit in our Barbara McInnis House. Peter and Bridget had never worked together before, but their skills complemented each other's perfectly. Bridget used to be a CPA. She's really freaking smart. She has great organizational skills and as funny as hell. Here's Bridget.

Bridget Sullivan: I was helping set up the COVID ward at McInnis house, and it was a late-ish night, and I was ready to go home. Barry asked me to stop by his office. We opened in 72 hours. So it was kind of a whirlwind. Like, from the second I heard about it, it was off and running.

Barry Bock: When we arrived at the convention center, there was already a ton of activity going on as led by Brigadier General Hammond from Mass General Brigham. Suffolk Construction was building out the space, which was truly a Herculean task, and General Hammond had made sure that there was appropriate PPE and support services along with the National Guard and the state and local police. It's important to visualize that we were building a COVID space in an empty exhibit hall. It was just massive.

Bridget Sullivan: The 500 beds you think would take up a lot of space and it probably took up a third and then it was just concrete everywhere.

Barry Bock: In certain ways, Boston Hope was like our respite facility, the Barbara McInnis House, where patients come and spend a week or two recuperating, and where we already had a COVID ward that Bridget had helped set up. But with Boston Hope we needed to build all of our systems, including figuring out patient flow, medical and behavioral health interventions, medication storage. So Peter and Bridget were hard at work designing a model that would care for 500 patients at a time.

Bridget Sullivan: So we have criteria for discharge, triage, high-risk versus low-risk, intake process, signage for EMS. How are we going to get ambulances here? Are we going to call 911? What's our documentation going to look like? How are we going to onboard staff? Where are we going to get staff? Who is the staff. The physical layout is down there on the list, but we didn't know what the physical layout was. IT infrastructure. How are we going to get medications here? Do we have internet? Are we gonna use EPIC? Any pharmacy issues. How are we going to get patients methadone, which is highly regulated? Supply and food delivery, bed control, intake. So it goes on and on.

Barry Bock: They were basically building a hospital-like facility from scratch in just a few days. But the mandate was clear to us.

Bridget Sullivan: I think it was Jesse Gaeta who was telling us we have two priorities: keep our staff safe, keep our patients safe. This is disaster medicine.

Barry Bock: And as if building a field hospital in the midst of the first wave of COVID wasn't complicated enough, we still had the rest of our work to do. One of the most difficult issues that we face,  that our patients face, every day is the opioid crisis, and as a result, the opioid overdose crisis. We knew it was not going away just because we had a global pandemic on our hands, and in fact, COVID might even exacerbate it.

Bridget Sullivan: That was our biggest concern. That's what's ravaging our community of patients, and it has been, and it still is to this day more than the COVID pandemic. And it's, it's devastating and it'll take your life in two seconds.

Barry Bock: You're listening to COVID in the Streets of Boston, a podcast from Boston Health Care for the Homeless Program. I'm Barry Bach. I've been on staff at BHCHP for the past 32 years, and I was CEO for nine years, including during the first few years of COVID. This is episode three: Boston Hope.
Overdose is the leading cause of death among our patients, and it was a major risk for patients at Boston Hope. With such a giant space, getting to a patient who was overdosing in time seemed next to impossible without the right safeguards and infrastructure.

Bridget Sullivan: You need to respond to someone in the first few minutes of an overdose. You can't go find someone. So we paid someone to be the walker through the place all the time. I mean, we were vigilant.

Barry Bock: These walkers monitored to make sure everyone in bed was safe. Every staff member carried Narcan, a medicine that rapidly reverses an overdose, and the team built in the safeguards into that space as well.

Peter Smith: We had the guy come in and reverse engineer all of the bathroom stalls and shower stalls to add reverse motion detectors so that if somebody was not moving in the bathroom, the alarm would go off and we could make sure that they didn't need to be resuscitated or get Narcan.

Barry Bock: We were fortunate to partner with AHOPE, the leading harm reduction program in the state, which is operated by the Boston Public Health Commission.

Peter Smith: These were by and large not healthcare workers, they were peers who were trained to do harm reduction and outreach, but they were really great bridges between the medical staff, I think, and the patients.

Barry Bock: Like Peter said, these staff were trained in harm reduction, which is a core tenant of our own program.

Evan Russell: Harm reduction has a lot of definitions, but I think if you try to boil it down to its core philosophies, it's like unbridled compassion, which seems a little hokey admittedly. But it really is like ignoring the stigma that is so inundated in our society and just accepting someone for who they are and the decisions that they make as their own and inconsequential to how their healthcare or their standing in society should be measured.

Barry Bock: This is Evan Russell.

Evan Russell: I'm a nurse practitioner and I've worked at Boston Health Care for the Homeless for five years now.

Barry Bock: Evan started with our program as a volunteer back in 2017.

Evan Russell: After I completed my BA up at the University of New Hampshire, I moved to Boston and I was looking for something to do. And so I volunteered here with the case management services, and then I sort of started working in the medical field. I applied as an MA and unfortunately didn't get the job back then. But I really liked it here and so when I went to nursing school, I got my first nursing job here and I worked in the clinic as I finished the NP portion of that. I did a clinical here and then started working as an NP shortly after graduation.

Barry Bock: That actually happens a lot here. People start as students are volunteers and then they come back as staff. We are quite fortunate to have a strong and talented staff, most of whom have long tenure years with us.

Barry Bock: Serious shout out to Evan. He embraced the ethic that we needed. He was well loved by his patients, and he was able to provide some additional administrative and clinical bandwidth for Bridget and Peter so they could begin to catch their breath. Evan would eventually become the associate medical director of Boston Hope. Melinda Thomas, the program's associate medical director for nurse practitioner and physician assistant practice, reached out to Evan to ask him to join, and that had a big impact on his decision.

Evan Russell: I've never had a manager like Melinda. She takes care of her people so well that I didn't feel like I would, I could be in a position to say no, and that, it's just kind of like, all right, this is it. The whole world's sort of falling apart. Like, you got to do something.

Barry Bock:  We breathed a sigh of relief when Evan said yes and he headed to Boston Hope, a very unusual scene

Evan Russell: I felt like I was the only car on the pike on the ride in, and you get to this giant convention center, and the parking lot's empty, and there are men in fatigues with pistols on their hips outside. And I remember the temperature scanner, cause we always used to check our temperature. It wasn't like, you know, someone with a forehead scanner. It was this giant military grade, I'm not even sure what it was, but it was, it felt like you were looking into the barrel of a gun. And it would point this laser at your head and tell you if you were febrile or not. And so it was so intimidating. It felt like a movie set. Like it, it felt unreal.

Barry Bock: And it felt eerily similar to a movie Evan had just seen a few months earlier.

Evan Russell: So in January I actually went to London with my wife and her family. And on the flight back, I heard about this new virus for the very first time. And then in flight, the movie Contagion was one of the in-flight movies. And I sorta thought to myself, “Oh, haha, I really liked this movie when it came out. I'll rewatch this.” And then over the ensuing months, when things got clearer and clearer that this wasn't just going to be a little blip and go away, I really regretted watching that movie on that flight because I started getting pretty worried about what was going to start to happen.

Barry Bock: The 2011 film Contagion features a deadly disease that's transmitted through respiratory droplets that soon becomes a pandemic. Sound familiar?

Evan Russell: There is a scene in Contagion where Kate Winslet goes to open up a field hospital in an old arena. It's like a hockey arena or something like that. And she's sort of mapping out where all the cots will go, and, you know, how many blankets you'll need and everything like that. And it never really hit me until we started doing things like the tents and Boston Hope like, oh, that's real. And, and I know you, if you haven't seen Contagion, I'm sorry for the spoiler, but Kate Winslet doesn't make it. She gets sick and dies in a hotel room alone. This is—sorry. I didn't expect to get emotional there. But, but it, you know, thinking back, that's terrifying, you know. There were times when we were at Boston Hope staying alone in a hotel across the street from a field hospital, and it was really scary what, what might happen.

Barry Bock: As far as anyone knew, those were the stakes. Yes, we knew about asymptomatic cases and yes, thankfully we weren't seeing a high death rate in our population yet. But we were still very early in the pandemic, and nobody really knew what was to come.
After just a few days of frenzied preparation, the Boston Health Care for the Homeless Program staff at Boston Hope began welcoming their first patients. The patients arrived literally in busloads from area shelters and by ambulances from area hospitals. Our goals were to give patients a safe place to isolate and receive optimal care and to give our shelter partners the relief of having a safe place to care for their guests who were COVID positive while protecting their other guests from contracting the disease. It was essential to also free up those hospital beds, and that became a huge priority for our program. All we had to do was look to our neighbors in New York to see how overloaded the hospital systems were. We were terrified that would happen in Massachusetts.
Each new patient was assigned to one of the curtained off rooms. Some patients knew the staff who greeted them, and others had never engaged with our program at all. Thankfully, for most  patients, COVID symptoms appeared to be mild to moderate in severity. We realized after the first few days that we needed to also focus more attention on the behavioral health issues that our patients had.  Two of the early staff members who joined Boston Hope were Sam Ciarocco and Georgia Thomas, both seasoned behavioral health clinicians.

Sam is our director of trauma services. She is also a brilliant behavioral health specialist in trauma care and harm reduction.  Prior to becoming a social worker, Sam spent 17 years as a bartender, and that always comes in handy. It's funny because Jim O'Connell, who's our founding physician, also talks about how bartending experience really helped him inform his medical practice. So anyway, Sam was fairly new to our program when Boston Hope opened. She joined the Office-Based Addiction Treatment team, also known as OBAT, just six months before COVID hit Boston.

Sam Ciarocco: Our OBAT program is a nurse care manager model known as the Massachusetts Model, where we have nurse care managers that specialize in treating folks with opiate use disorder to manage their disease or diagnosis with Suboxone. But then we also have a recovery coach on the team who's a peer support, and we have behavioral health clinicians. So it's a very team collaborative approach to helping individual patients with where they are in their substance use disorder. And the hope is to get them into remission and be able to, you know, manage the way they want to live their lives without having everything that an opioid use disorder impacts.

Barry Bock: Suboxone is one of the medications used to treat opiate use disorders. It's the brand name of the drug called buprenorphine. Another medication for opiate use disorders is methadone. Suboxone and methadone can be lifesavers and reduce the risk of fatal overdoses.

Sam Ciarocco: When you're in that work every day, that's kind of the driving force and what you're thinking about—just, like, reducing the likelihood of this patient dying. Even if it's not to have them never use opiates ever again. That's not realistic. But we do have tools that can prevent people from dying if they do use. And we were really focusing on trying to find ways to make sure that everyone had as easy access to that as possible.

Barry Bock: Pre-COVID, this work happened almost entirely in person. Once COVID hit, providing access to care got even more challenging.

Sam Ciarocco: So at the beginning of the COVID-19 pandemic really hitting, that's really where our team had to focus on, okay, what can we do via telehealth? Can we get meds delivered to people? How do we do longer scripts so they only need to go to the pharmacy once a month instead of every week? And really trying to reduce their exposure in the community while still being able to stay on their medication. Because I mean, at that point it was almost like what's going to kill you first, an opiate overdose without your buprenorphine in your system, or COVID by going to the pharmacy and getting your script?

Barry Bock: Behind the scenes, our intrepid chief operating officer, Barb Giles, was busy working with the Massachusetts Department of Public Health and the Federal Drug Enforcement Administration to ensure that what we were doing at Boston Hope was meeting all the state and federal standards and still focused on meeting the ongoing needs of our patients across the rest of the program. Barb has been with Boston Health Care for the Homeless since 2008, first starting as a clinic nurse and she is currently the chief operating officer. She's the linchpin of our program. And honestly, just a shout out to the Department of Public Health and the DEA, both of whom were amazing to work with.
So now back to Boston Hope. When Boston Hope opened, Sam immediately saw the need to support the patients who were being treated for opiate use disorder with Suboxone or methadone in that space, too. So she worked out a system to bring medications to patients there and help new patients access medication-assisted treatment, which is the gold standard of care in medicine.

Sam Ciarocco: We had quite a few people who came into Boston Hope who had not yet been interested in medication for opiate use disorder, but because they were going into withdrawal started on Suboxone. And one person in particular was really like, I'm only doing this so I don't feel awful and because I have nowhere else to go. Just give me the medicine, and actually stayed on Suboxone for quite some time after leaving Boston Hope, which I found was truly remarkable. And even more remarkable about how many referrals we were able to do for our OBAT team from Boston Hope, for people who were interested after those 10 days in really getting connected to care.

Barry Bock: That was another major goal for us: helping patients who first found us through Boston Hope to stay connected with our providers even after they left. But addiction care wasn't all Sam was doing.

Sam Ciarocco: During this entire time, I was also setting up all of telehealth for our agency.

Barry Bock: We did not go into 2020 with the infrastructure for telehealth. Between the technology access and the billing systems and our emphasis on building person-to-person relationships with our patients, telehealth just wasn't part of our regular routine. But as luck would have it, Sam had been working on a grant to provide behavioral health supports via telehealth for patients who used our Community Care in Reach outreach van. So she had developed something of a framework for making telehealth work with our patient population. Mass Health, the state Medicaid program quickly sorted out the billing structure for virtual visits and our IT department did an amazing job getting our tech systems in place with that support. During the peak of the pandemic when people were isolating, Sam was able to transform almost 50% of our important behavioral health visits into telehealth, including visits at Boston Hope.

Sam Ciarocco: I had set up these like amazing little telehealth suites at Boston Hope where there was an iPad, but there was also stress balls and a notepad to write notes and instructions to be able to like log into the Zoom so people could do it a little more independently. Most people really enjoyed being able to go into this more therapeutic space in this big cavernous place to be able to talk to their providers. Especially patients on Suboxone and part of our OBOT program really liked that they were still able to see their nurse via telehealth, and it gave them a level of comfort to be able to see a familiar face because we were all dressed like beekeepers. And we had people from all over our program there so a lot of our patients didn't know the people that were there. So I think having that video option was really important just to help people feel connected still, especially connected to their existing providers.

Barry Bock: Creating this sense of connection and continuity of care was essential for patients, especially during the early days of the pandemic. Our patients deal with a disproportionate amount of mental health challenges, and like the rest of the world these issues were exacerbated by the pandemic.

Sam Ciarocco: When people are sick or going through a hard time, you rely on your community for support. Whether that community is your family, your friends, people you grew up with, your coworkers. And for our patient population, those supports and community exist in shelters, in programs, out on the street in encampments. You know, for our population that community is sometimes all they have, and we were really telling people, “Hey, it's not safe for you to be around the people that support you.” And that's really isolating. So for people who had already had diagnoses of depression, anxiety, all those were made much worse by coming into Boston Hope.

Barry Bock: Making sure patients remained connected to care and on their medications made a huge difference to the patients' health and morale. But if we were going to be able to keep patients at Boston Hope for the 10-to-14-day isolation period, we needed them to feel connected to the people around them, too, to have a sense of community. Remember, it was voluntary that a patient stay with us.

Sam Ciarocco: We learned very quickly telehealth is great, but it's not for everyone and it's not for every situation. So we still needed someone there in person to be able to help with crisis intervention, deescalation. And Georgia was the first clinician therapist who stepped in and was like, “Sam, what days do you need me there? I can do this. I can work weekends. I can, I can do whatever you need me to do. Just tell me where and when to go.” And so we were able to have a full schedule of behavioral health support because of the work that she was doing there.

Georgia Thomas: So my name is Georgia Thomas. I'm the director of behavioral health in respite.

Barry Bock: Georgia has been part of our program for more than 20 years, and she has held a number of different positions throughout. She's a therapist with a tireless work ethic. Her behavioral health work is truly exceptional, especially doing trauma care, caring for people with substance use disorders, and caring for women who have experienced intimate partner violence. And Georgia and Sam always show up. They don't wait to be asked. Georgia saw a need at Boston Hope, and she stepped up to help.

Georgia saw that COVID was bringing up a lot of anxieties for our patients and not just about getting sick. Patients who had been incarcerated were scared of feeling confined. People were afraid of the ways that healthcare institutions had treated and marginalized them in the past. And now they were being told they had to wear masks, and and they were meeting staff now in full PPE, and this created a depersonalized atmosphere. It was a confusing new world, and there were a lot of compounding traumas at play,

Georgia Thomas: Think about, you know, folks’ intergenerational experience, trauma, you know, traumatic experience or experiences with the system. Some of them will dwell on that. And sometimes by, you know, hearing people talking like that, it can also cause barriers for them to treatment because of the fear.

Barry Bock: When people don't know what's happening, they fill in the blanks, and that's what happened with COVID, especially with places as new and as different as Boston Hope. Some of our patients have a lot of mistrust of systems and were worried that they might be treated different because of their circumstances.

Georgia Thomas: And I took the opportunity to educate them and say, “No, think about it this way. this is something that's like, it's a virus that that's affecting the world. You know, it's a shared experience.”
Barry Bock: With all the infrastructure in place, Georgia and Sam were able to step right in and start doing the work that was within their specialties.

Georgia Thomas: I was able to provide individual counseling, you know, mental health counseling to those patients who wanted to meet with me. I was able to provide therapeutic groups, meaning if they wanted to talk about their anxiety, depression, or just to do a quick check in about their experience at that time at Boston Hope.

Barry Bock: Georgia was able to connect with patients, some of whom she had longstanding relationships with, including a man she'd first met at our Long Island shelter clinic more than a decade before.

Georgia Thomas: And when I went to Boston Hope, even though I was like in that suit, he remembered me. Because he's like, “Oh my God, Georgia, you had the baby.” I said, “Oh yes, that was 12 years ago. But yes, I had the baby.” So as an African American man seeing me there, it was more like a sense of like reassurance for him, a sense of relief: “Oh, Georgia's here as one of the team members to support us here, so I'm okay.”

Barry Bock: Patients were able to build on that trust and help each other feel safe, too.

Georgia Thomas: That guy that I saw at Long Island many moons ago, he was in one of the check-in group. He's like, “Hey, Georgia. Listen people. Georgia's cool. She's cool people. She's cool people.” You know, which was kind of like, oh, okay. So he's giving me some prompts there. It's just to kind of like, let's just start building the little relationship.

Barry Bock: For a lot of our patients, healthcare is not one of their top priorities. Before we can meet a person's health needs, we need to ensure that we build trust and meet them where they're at. That's part of our mission.

Georgia Thomas: Think of the hierarchy of needs for these individuals. The food, the clothes, the place to sleep, the, you know, just being there, love to support them emotionally. The population that we serve, the majority of the time they don't have that. Living on the streets, the shelters, they've been isolated, rejected, abandoned by their own loved ones, because it could be because of mental illness. It could be because of addiction or being evicted. Or it could be even natural disasters for whatever reason in life.
When I used to work in the clinic, if someone comes in, it's like the first thing I would ask, depending on the time, if it's lunch time, “Have you had lunch already?” “Oh no, I never had anything.” “Okay. Is it okay if I go grab you a lunch upstairs?” If it's in the morning, “Have you had breakfast? Do you want you wanna eat something?” “Oh yeah, I can get something.” I go upstairs and get a donut or a bagel or something. Bring them coffee in my office. And then we create a conversation right there. Once you build a relationship with some patients and the trust, they will keep coming back.

Barry Bock: At Boston Hope, patients had all their basic needs covered. Patients received three meals a day and snacks every single day. There were showers and an outside gathering space, and and everyone was guaranteed a bed with privacy. They didn't have to get up and leave a shelter at 6:00 AM or worry about finding a place to spend the night. But aside from receiving healthcare and meals and shower times, the schedule was pretty open, and that brought its own challenges. Here's Sam again.

Sam Ciarocco: There wasn't a whole lot to do at Boston Hope. Like none of the people here are going to have significant symptoms when they come in. A lot of them are going to be asymptomatic. They're not going to be able to leave or do anything. And it's like, we need stuff for people to occupy their time with because boredom is a big impact on someone's mental health and mental stability.

Barry Bock: Plus if you're bored, you're not likely to stay

Sam Ciarocco: So worst case scenario was that people would leave Boston Hope and continue to spread the virus throughout the city, and that more people were going to fill up the hospitals and die.

Barry Bock: We couldn't and wouldn't keep people at Boston Hope against their will, so we needed incentives for them to stay. The team did basically what we do in our respite programs. They came up with activities and games for patients to keep them busy and to help build community. And our partners at Mass General Brigham were very gracious in sharing their donations with our patients.

Sam Ciarocco: We had a library, we did yoga. Someone donated the Boston Globe every day so people could still be up with current events and read the news. Not that anyone wanted to at that time. And we played a lot of cornhole. I played a lot of corn hole with patients in full of PPE.
Barry Bock: With all these activities, the team discovered yet a new wrinkle.

Sam Ciarocco: There was one person who had recently been released from a long incarceration and upon getting out and trying to go to the shelter, they tested him and he was positive for COVID. And he was like, you know, you come in here, you have all this stuff around, but we don't know what's here. You guys should have like an orientation group. So we created one.

Barry Bock: And they invited that patient to help run it.

Sam Ciarocco: I really enjoyed running those orientation groups with him because what we quickly learned was that we're talking to people, not knowing what they're going through, what they're feeling. He was able able to, to provide his own personal experience with it. And then once he, his quarantine was over, we got another patient who really enjoyed doing it and was really involved in all the activities.

Barry Bock: And of course, they decided to make activities into, well, an activity.

Sam Ciarocco: So you got a punch card when you came in, and if you did at least one of each activity on the punch card, upon your discharge, you got a backpack full of stuff that you could leave with. And there were activities like doing physical exercise group, going to orientation group, going to a recovery group, meeting with a case manager, playing corn hole, doing puzzles. And it wasn't a lot of things, but if you're going to be there for 10 days, you can easily get all of them done.

Barry Bock: Ideally, these activities would help pass the time and build community and would have a short and longer term effects on our patient's health and wellbeing. ideally these activities would help pass the time and build community and would have a short and longer term effect on patients' health and wellbeing.

Sam Ciarocco: I think I was really hoping once people had completed the isolation/quarantine time that they saw Boston Health Care for the Homeless as an organization that is able to help and support them through a variety of needs. And that they had resources to be able to like, live a happier, more fulfilling life. That's really my hope. But mostly just to not die.

Barry Bock: Some patients needed more individualized support to make sure they would make it through their time at Boston Hope. Here's Evan again.

Evan Russell: I do primary care, but I also do substance use disorder. And so the people I see generally have pretty chaotic lives and, and our relationships are sort of transient. We'll work really closely for three months, and then I may not see them for a little while, and then they'll come back. And, you know, there was one young guy in particular who, who I had not seen for months, and he was in a bad way the last time I saw him. And so it really was like, thank God he, nothing horrible horrible happened. But I also know from our history together that this is not the kind of situation he's going to do well in. Like he doesn't go to shelters. He stays out on the streets for his own reasons and they're valid reasons. And to put him in a cot in a giant room where you can hear everything, and the lights go down but they never quite get dark, and there are big guys with guns at all the doors, like, you know, it's not where he wants to be. And he's got COVID. So it's like you're taking every scenario and then cranking it to 11 for his anxiety. And we discussed that when he got there. I was like, “Hey, I know you, you know me, I know this is not going to be a good situation for you. What can we do?” And we tried to find different solutions. Like he really likes listening to music. He really likes writing. So we got him as many pens and pads of papers we could, and he just wrote a ton of poems and stuff like that, wrote down every song lyric he could think of, but it was a lot of checking in and, and seeing how things were going day to day.

Barry Bock: Often, helping people get the individualized care they needed at Boston Hope involved coordinating services in the broader community.

Georgia Thomas: Whenever I'm there, I checked in with pretty much everyone just to see if they needed some kind of psychological support. And there were two Haitian patients there, but one of them was very stressed out about his apartment. He had friends and family members in his apartment and he was afraid that he was gonna get evicted. So I sat down with him, cause he didn't have access to a phone. We called the friend in the apartment and talked to him and said, “Look, let's just see if we could just keep things very quiet. Try not to break anything.” And I was able to help him to get a money order as well, to send to the landlord, to pay for his rent. And you could see his anxiety, you know, kind of, it was more like a sense of relief. Like, “Oh, thank God. So this is taken care of. I felt better now.” You know, just to show you the minuscule that you could do for someone, sometimes what I say to people, you don't have to be a therapist to be therapeutic to someone. As long as you can sit there and build a relationship, the connection, it makes a big difference in someone's life.

Barry Bock: That kind of relationship building and service coordination is a lot of what case managers do in our program every single day.

Pamela Sprouse: Case management is making sure that your patient has access to their basic needs on a daily basis, like meals, transportation to their medical appointments or to the supermarket, connection to care, appointment reminders. At some point you become their therapist, their friend, their only option. The case manager's basically the glue that is gonna bring the patient to the rest of the team.

Barry Bock: This is Pamela Sprouse, the co-director of Harm Reduction Services. Pam is another star in our program and she has been with us for over a decade now. When it became clear that we needed to build in case management services at Boston Hope, we turned to Pam and her colleague, Caitlin Pollard.
Case managers played an important role at Boston Hope, and they helped us individualize patient care. Remember, our foundation of care is about meeting a patient where they are and recognizing their resiliency. Then we designed the care around supporting that patient's strengths strengths. At Boston Hope, case managers like Pam and Caitlin were doing a lot of connecting.

Pamela Sprouse: We did work with a group of people that were doing construction at that time. So making sure that their employer was updated on their return date in order for them to be able to return to that person. We did a lot of rescheduling of appointments, Even though these specialty sites were closed at that point, it was hard for some of our patients to understand that they were not missing this appointment. Like it was already canceled, but like making sure that they knew that this was gonna be rescheduled at some point. And even helping them find family and Facebook, Instagram instant message to people that they will only see on the streets, but now they don't know their phone number. They don't have access to a phone or know how to reach them any other way.

Barry Bock: So case managers are often the connectors, but Pam is quick to point out that we in healthcare are not actually in charge of patient care. The patients are.

Pamela Sprouse: I feel like a lot of times our patients don't give themselves the credit they deserve. They accomplish so many things and they will thank their case manager or their provider or someone that is in their support network. But I keep telling our patients—and this is my approach—that they're the driver. I'm just a passenger. I'm next to you. I'm gonna be changing the radio station for you. I'm gonna be doing whatever you need me to do. And then once you wanna continue to drive, I'm gonna be right there next to you, but you're the driver. So like, it's your choice, your call. If you wanna stop or if you wanna keep going, I'm gonna be sitting right next to you.

Barry Bock: Boston Hope opened in April, 2020. A time of panic and confusion. One thing that really stood out for me was seeing the morgue truck for the first time in the back lot of Boston Hope. We were hearing reports from New York of morgue trucks that were completely full parked outside of hospitals, and now there was a morgue truck parked right outside of Boston Hope for what we could only assume were the inevitable fatalities. But that truck was thankfully never needed.

Peter Smith: I still don't completely understand how we lucked out as much as we did how our patient population was spared the COVID mortality that we all feared would happened. Because our patients do have, you know, more than 90% of them smoke. You know, there's really high rates of COPD, and emphysema, and hypertension that's untreated, and heart disease, and diabetes, much more than the regular population. And we didn't see large numbers of people experiencing homelessness die from COVID. I think part of the credit for that goes to a lot of the early screening, early identification of cases, making sure that we isolated people who were contagious, that we really devoted a lot of time and resource and a lot of thoughtfulness to all the different COVID treatment and isolation activities that that happened. But still I'm, I'm, I'm, I'm baffled by how lucky we were even, even taking that all into account.

Barry Bock: I give a lot of credit to our remarkable and heroic staff who, because of a sense of mission and duty and commitment to our patients during a very scary time when we didn't know what was happening with the disease, when most folks were staying home, our staff donned their PPE and entered COVID spaces like Boston Hope to care for our vulnerable and complex cohort of patients who really had no one else. It cannot be overstated how profound this commitment was by my colleagues. I remain truly in awe.

Sam Ciarocco: While there was all this unknown out in the world, we knew exactly what was happening at Boston Hope. We all had very clear, defined roles. We were supporting people through a variety of means and mechanisms for not just COVID, but mental health, case management, housing, getting connected to care. I think that was like one of the best successes that we were able to offer people was just getting them connected to care that they would've never felt the need to get connected to based on their stage of change at the time.

So everyone was like part of this very mission driven team that, that we were trying to accomplish something great. Not just for our patients, but for Boston in general, knowing how important it was that like, we're not going to reduce the curve, flatten the curve, if we don't have a place for people without homes to isolate. Like, libraries are closed. Dunkin' Donuts is closed. Can't use the T. Where will you go except out in the community, spreading this virus? So I really do feel like by having the space for Boston Hope we were really able to help mitigate COVID for all of Boston, not just for our patients. And I think everyone who was working in the space and the patients there, they knew that this is what they were doing to keep their community safe, too. And we really tried to make it a strengths-based experience for people and recognizing and thanking them for doing that. Because people could have left and they could've said no. But we were able to build in supports that allowed people to be more comfortable with saying yes and staying.

Barry Bock: The Boston Hope Field Hospital remained open for just over two months and treated 700 patients in total. Some patients wanted to stay even once they had recovered. They saw Boston Hope as more than just a field hospital. It had become a community.

Peter Smith: One of my more vivid memories was welcoming one patient in and bringing him to his bed after he got checked in and got his little bracelet. And he was just looking around at the space and saying like, “It's incredible that, you know, they really, they must have spent enormous resources and in putting this all together and creating this place for us.” And, you know, then he sort of thought about it and said like, you know, “Wouldn't it be amazing if all the time they put this kind of resources in, in creating spaces for us, because we should have this all the time.” And he was right.

Bridget Sullivan: Just to be clear what he was saying, “This is amazing,” was drywall, cot with a sleeping bag on it, a little nightstand table with a key, and cold sandwiches. I mean, it wasn't, I don't want it to come off that this is some five-star hotel we should put putting everyone in. It was very basic, clean, caring people providing a safe space for our folks. And that is kind of where it touches home for us is that this place would be a place that people wanted to stay even during a COVID pandemic, even when we didn't know if you'd be reinfected the next week, you know, people were begging to stay. I mean, to think that you would rather potentially put yourself at risk to this unknown virus to stay in a place with concrete floors and cots and sleeping bags is really telling of some of our folks and just how grateful they were what we were providing there. It was almost like a little community at the end, and I think we were pleasantly surprised at how well it went.

Barry Bock: like all of us, our patients deserve the highest quality of care no matter what their circumstances might be or how they got there.

Georgia Thomas: No one has ever chosen to experience homelessness. Many things happen in life and unfortunately you end up on the streets, or the shelters, or couch surfing, or sleeping in your cars, alleyways, because of a myriads of reasons. Just because someone is experiencing homelessness, that doesn't mean this person is a bad person. You know, circumstances in life, bring that person to this, to where he or she, or they are right now. Oftentimes society, who just see someone on the street asking for money or whatsoever, they often treat, treat them like “the addict.” You know, that's the word that is very stigmatized, you know, to someone who use substances. Not knowing that or not having the knowledge that addiction is a disease. That that person is struggling. And I think serving folks who are experiencing homelessness and coming here to Health Care for the Homeless to make them feel like they belong, you know, they are loved, you know, they deserve the respect and dignity that all of us deserve. The way we greet our patients, the way we serve them, it is different than going somewhere else. Coming here, it's like, it feels like home to some of them.

Barry Bock: Thank you for listening to this episode of COVID in the Streets of Boston. You can find the first two episodes of the series in Apple Podcast, Spotify, or wherever you listen to podcasts. This is our last episode for now, but please subscribe to the show to stay updated about any future episodes or other audio projects we might produce.

Credits: This episode was produced by Galen Beebe and directed by Sarah Pacelle. It was sound designed, mix and mastered by Jack Pombriant. Music from the Epidemic Sound Library and Jack Pombriant. Thanks to our intrepid Boston Hope leadership team that contributed to this podcast, especially Peter Smith, Bridget Sullivan, Georgia Thomas, Pam Sprouse, Sam Ciarocco, and Evan Russell. We are grateful to our IT staff for helping to keep the engine running.

Our deepest thanks to all staff members who worked in Boston Hope in full PPE at a time when there was so much unknown and frightening about the virus: the nurses, the nurse practitioners, doctors, case managers, social workers and facilities staff who donned their PPE fearlessly to care for our patients with the dignity and respect they deserve. You can imagine that so much was happening behind the scenes as well, and we could not have pulled this off without the steady hands of Barb Giles, April Ramsey, Jesse Gaeta, Denise De Las Nueces, and Mary Takach. We are grateful to all of our heroic staff who care for our remarkable patients and those who support the caregivers. Our kitchen staff, our dedicated board of directors, our remarkably kind donors, many of whom gave without ever meeting a single staff member. We're thankful for your trust. Thank you to our 30+ shelter partners and hospital partners, especially Boston Medical Center and Mass General Brigham, 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. Our deep gratitude goes out to Governor Baker, Secretary Sutters, the State Police and National Guard, Boston Police Department, and to Sheila Dillon from the Mayor's office. Finally, we could not have pulled off our 500 beds at Boston Hope were not for the collaboration and all of the preparatory work of Home Base, a program of Mass General Brigham. And of course, we thank our resilient patients who have had so many struggles in their life but continue to teach us every day about our shared humanity. And thank you for listening.