A pair of experts with Healthcare for the Homeless share their perspectives working with unsheltered populations and addressing homelessness. Kat Donnelly, a family nurse practitioner with Minnesota Community Care, and Josh Leopold, a senior advisor on health, homelessness and housing for the Minnesota Department of Health, join the show to talk about what’s being done in St. Paul.
A pair of experts with Healthcare for the Homeless share their perspectives working with unsheltered populations and addressing homelessness. Kat Donnelly, a family nurse practitioner with Minnesota Community Care, and Josh Leopold, a senior advisor on health, homelessness and housing for the Minnesota Department of Health, join the show to talk about what’s being done in St. Paul.
Hosts: Kari Haley, MD, and Steven Jackson, MD
Guests: Kat Donnelly and Josh Leopold
Resources:
HealthPartners website: Off the Charts podcast
Got an idea? Have thoughts to share? We want to hear from you. Email us at offthecharts@healthpartners.com.
Kari Haley:
He's a rehab doctor from Chicago.
Steven Jackson:
She's an emergency medicine doctor from the Twin Cities.
Kari Haley:
Together we're examining the health equity emergency.
Steven Jackson:
Inviting voices for change without the cue cards.
Kari Haley:
I'm Dr. Kari Haley.
Steven Jackson:
I'm Dr. Steven Jackson.
Both, together:
And this is "Off the Charts."
Steven Jackson:
Welcome to "Off the Charts," where we examine the health equity emergency. On this episode, we're focusing on homelessness and specifically the unhoused population in St. Paul, Minnesota. Joining us are a pair of guests who know the topic very well. Kat Donnelly is a family nurse practitioner with Minnesota Community Care and Healthcare for the Homeless. And we also have Josh Leopold, who is a senior advisor on health, homelessness, and housing for the Minnesota Department of Health who also works with Healthcare for the Homeless. So welcome, guys, and thank you for being here.
Kat Donnelly:
Thanks for having us.
Josh Leopold:
Thank you.
Kari Haley:
Thank you so much for being here. I think just to start things off, if you guys want to maybe give us a little bit more about who you are and what you do for your job, and then let's dive into the more good, hearty questions.
Josh Leopold:
Sure. Yeah. So I've been in this position with the Minnesota Department of Health for coming on three years, and it's a relatively new position that the Health Department created really in response to the COVID pandemic and the recognition that that created around all the ways that housing and lack of housing can influence people's ability to follow public health guidance and really keep themselves safe and healthy. So I serve basically as the subject matter expert within the health department on issues related to homelessness and then also as a liaison to other state agencies on homelessness planning and policy, and then a lot of communication to local partners, both health care partners and homeless service providers.
Steven Jackson:
Kat.
Kat Donnelly:
Yeah, I am Kat Donnelly. I work at the clinic inside the former Dorothy Day shelter, now St. Paul Opportunity Center. This is my ninth year doing that. And we do primary care for people who both live in that space, the shelter, and people who are unsheltered. My main job is with the unsheltered population here in Ramsey County.
Kari Haley:
And maybe just for our listeners to maybe make that distinction and what is that distinction between the population who are sheltered and not sheltered?
Kat Donnelly:
Sure. Some people are accessing shelter on a regular basis, either the overnight shelter, the longer term programs within the shelters, various different avenues there. And some people are living primarily outdoors, and the people who are living outdoors is my patient population.
Steven Jackson:
So what led you guys to this career path and the work that you guys are involved in? What is the origin story, so to speak?
Josh Leopold:
Well, so for me, I was working in the federal government. There's the United States Interagency Council on Homelessness during the Obama administration. And just so happened that a lot... I mean this is a small agency. I think in total, maybe there's 10 to 15 people, but it felt like half of them were from Minnesota. And then I was living in Washington DC, and then I moved to Minneapolis in 2019. And at the time I was working for a research organization called The Urban Institute. And then in March of 2020, reading the headlines, seeing what was happening with COVID, and so some of the projections that folks were making about how this was going to impact people experiencing homelessness reached out to former colleagues at the US Interagency Council who are now back in Minnesota working in state government. And that's how I got involved working for the state of Minnesota doing the COVID response. And then that led into this role at the Health Department.
Kat Donnelly:
Nursing is my second career. I started out in physics. I was a linear accelerator for a lot of years and lived out west. Not going to be like...
Kari Haley:
A whole 'nother life.
Kat Donnelly:
I will sum this up. I had somewhat of an irregular schedule. And so around that I was able to do volunteer work with search and rescue, which got me interested in health care. And at that time, there were a lot of incentives to go to nursing school. I was a wilderness EMT already, and so it seemed like a natural thing to try. And I did a secondary baccalaureate degree in nursing. And then I worked at HCMC (Hennepin County Medical Center) for almost 10 years doing labor and delivery there. And then I had children and didn't want to do night shifts anymore and went to graduate school and worked a year at Planned Parenthood and then found the job here at Dorothy Day. And I really credit my former boss with both the interview process and selling me on the job and then creating the job that I'm in now. When we shifted from the old Dorothy Day shelter, if you remember the old concrete structure, that's where I started. We were really mainly in clinic. We were maybe outdoors four hours a week.
And then we moved over to Mary Hall while the new building was built, and COVID happened and we shifted to being primarily outdoors. There was the shelter-in-place order. And so the encampments got very, very large, and people were very reluctant to come indoors to seek health care. We, in fact, were doing most of our health care out of a three-sided tent outside the clinic. And we were all sort of inventing our own jobs in that time. And so when that happened, I shifted to being primarily outdoors. And it has been such a powerful place to be that I haven't ever gone back to being an indoor clinician. It's really been sort of the population that has needed quite a lot of help. And it's a natural fit with the willingness to be outdoors that I came in with and the the ethic of Healthcare for the Homeless.
Kari Haley:
Absolutely. So, Josh, I heard you speak at an EMS conference earlier this year. And things that really stuck out to me because I feel like as an ER (emergency room) and EMS (emergency medical services) physician, I kind of know things. We see a lot of the similar populations of people who are unsheltered and sheltered. We see the problems that happen within these communities. But what really struck me was some of the data that the Minnesota Department of Health just recently came out with in the last few years about the statistics surrounding that. So if you don't mind maybe going a little into telling us a little bit more about some of the morbidity, mortality statistics because it honestly blew my mind, even though I live it and I see it, and obviously, it was within my realm of reference. But I think that for other people who is not even in their realm of reference, some of these statistics, if you don't go look for them specifically, you're never going to hear them. So I'd love to see if you are able to give us a little highlight reel.
Josh Leopold:
Yeah, thank you. So we partnered with, we, MDH, partnered with the Hennepin Healthcare Research Institute to do the first ever state homeless mortality study. And so we looked at data. There's something called the Homeless Management Information System, which is a federal requirement that homeless programs collect some basic information about the people they serve. And that could be in an outreach setting or in a shelter or in transitional housing or supportive housing program. And so in Minnesota, all of that data is administered by one statewide partner. So there's a way to access the data at the state level.
And so what we did is we got data that's been de-identified. So we didn't get anybody's name or date of birth or anything, but we were able to see all the records for everyone who's used one of those programs between 2017 and 2021. And then we merged that data with our state death certificate data, and then also with population data for the state of Minnesota. Then we were able to compare a person's mortality rate. So basically their risk of dying during that five-year period between people who had used the homeless program and the state of Minnesota as a whole, adjusting for some natural differences in terms of people who are experiencing homelessness are on balance, much younger and more likely to be male than the state population. And both of those things influence your mortality risk.
So once we leveled the differences between the populations, what we found was that people experiencing homelessness, their risk of dying during that five year period was three times higher than the general population. And a 20-year-old who was homeless had about the same mortality risk as a 50-year-old in the general population, which is consistent with what we see in other data in terms of how, and I'm sure Kat can speak to this from her experience, of how homelessness can prematurely age somebody at 20 to 30 years to what their calendar age is. So the overall risk was three times higher.
We saw even greater disparities, particularly for American Indian people experiencing homelessness. And for that population, the rates were five times higher than the general population for Minnesota. So during this period, even though we are capturing the height of the pandemic, more than a third of the deaths we saw, the primary cause listed was substance use related. This is really the period where we started to see fentanyl, the illicitly manufactured opioid really get a foothold in the Midwest in Minnesota and really supplant prescription opioids and heroin as the primary opioid that's street usage. Yeah, so that was the leading cause of death that we saw during this time period. The people experiencing homelessness, their risk of dying from a substance use related death was about 10 times higher than the general population.
Steven Jackson:
So Kat, from a medical perspective, I guess, what are you seeing firsthand when you're out in the community? I know we talked offline about some of the effects of some of the substance use and what's some of the other things that we're seeing out there?
Kari Haley:
Yeah. Is it matching similar? Does it seem like it matches the data, like your actual experiences?
Kat Donnelly:
Yeah, I think this is the same data you're presenting at the statewide conference, yeah. And so it's interesting to see it added up because I have one person in front of me at a time usually.
Josh Leopold:
Right.
Kat Donnelly:
And so it makes a lot of sense that the things that people go through on a day-to-day basis are incredibly stressful and traumatic. And that chronic PTSD exacerbates every other health condition that they're already coping with in addition to not a lot of access to quality food, not a lot of access to quality rest. And the environmental challenges of being outside, keeping yourself warm and fed and safe.
Steven Jackson:
Do you see more of, and I can only assume you see more frostbite and things like that when it's colder, but just in general, are there more conditions medically speaking and otherwise that you guys see when it's as dreadfully cold as it has been, I guess last week now?
Kat Donnelly:
Yeah, we were talking a little bit earlier about frostbite, tons of frostbite, and I think last year was also very, very cold. Two years ago was phenomenally cold. And so we go through these cycles of, especially in the service provision where we're starting to see, we'll see a few, and then we see many, many, and then it winds down. But then there's always the ones that were very, very complex or didn't get care right away. And then they're going into the next year with that same chronic wound, still trying to close those wounds, still trying to keep them clean. And it just compounds, and you end up with amputations and things like that.
The other thing that we see quite a lot of is the injuries of people trying to stay warm. And so burns from fire, carbon monoxide inhalation, smoke inhalation. It's very challenging, especially, like it's 40 degrees today and so it doesn't feel like you would necessarily need heat, but it's in fact for hypothermia, one of the most dangerous temperatures because you have this idea that you're going to be warm and then the sun goes down. People heating their structures will often use whatever they have at hand to stay warm through the night.
Steven Jackson:
We have winter every year, right. And we have some of the new wounds as well as the chronic wounds every year. Are there any programs, are you guys affiliated with any programs that talk about prevention? And excuse my ignorance, I mean obviously we have an unhoused population and there might be a lack of resources or other things that I'm not familiar with, but is there anything that can be or is being done in terms of winter's coming in a few months, let's do some education, or here's a program that we want to offer that might offset some of the things that usually are inherent with these dangerously low temperatures?
Josh Leopold:
Yeah, well, as you said, winter happens every year and it's usually cold here, at least can be brutally cold for stretches pretty much every winter. St. Paul included typically have hypothermia shelters that they open. They expand their shelter capacity in the winter to take on more people who probably wouldn't go into shelter when it's 50 or 60 degrees, but if it's negative 10 might go into shelter. Kat, curious to get your perspective on this. I think some people are generally kind of resilient and can plan for winter and have places that they can go where they will put, for better or worse, propane heaters or whatever in their tents or structures. So I think all of that can help prevent it. I think one of the things I'm concerned about now is more of the extreme heat, which I think people were not, I think as a state as well-prepared for in terms of the risks for people experiencing homelessness of extreme heat. And we don't have cooling centers in the same way that we have warming centers. So I think that's a emerging concern.
Kat Donnelly:
Definitely.
Kari Haley:
I've read a few books recently too about programs that other institutions have, other places that have had probably longer experiences with unhoused populations. So like in California out west, East Coast, and like what we have necessarily here in Minnesota but alluding more to what you do in terms of being out in the streets and actually seeing people in the street. Can you tell me more about your program? How many people are doing this? What is your reach basically of the population that you're seeing?
Kat Donnelly:
One of the best things about our job right now has been community partners. And so we work really closely with the other agencies that do unsheltered outreach. And so usually if people, other outreach workers see something that they're concerned about, St. Paul is small enough that we all know each other. And so it's easy to get in touch and say, this person is here, they're looking like they might need you. Can you come by? When can we make that happen? Right now at Dorothy Day, we have three providers and two, three nurses. And as far as mobile health, as far as our outreach program, we've been as big as four. Right now it's me. And so it has been invaluable to have outreach partners.
Kari Haley:
Yeah, I would imagine.
Kat Donnelly:
Community partners where you can not only connect with people, so you can either find your patient or learn about people that want to be seen.
Josh Leopold:
Yeah, and I would say from my vantage point, one of the things we've seen I think really accelerated with COVID is this growth in mobile medical providers and backpack, street-based medicine. And so we've recently started trying to at the state, try to convene those providers to get a better sense of what they're doing, who's doing what, and where we can be making connections, where we can be supporting those kinds of efforts for the long term because we know it's very difficult when you're homeless to schedule an appointment, make an appointment. So whatever care that we can be providing out in the community is going to go a long way, especially preventative care and then just focusing. It is not going to replace the need for specialty care, but whatever we can be doing out in the community, I think is going to be really beneficial.
Kari Haley:
Absolutely. From the state level and then even the individual, the community partners, what can we be advocating for? What can we be doing to help make this a priority? Because it is a big... When you hear that three times your mortality rate, that for young people who would otherwise, if you have the same mortality risk at 20 as you do at 50, those numbers blew my mind and was just like unreal. And it was like, this is a really big deal that I feel like not a lot of people are necessarily talking about in the health care field. So what things can we be doing to try to advocate and help move at least knowledge around, I would say versus we're not ever going to solve anything but move knowledge in the right direction.
Kat Donnelly:
I'm not a policy person.
Josh Leopold:
I mean, it's a great question and it's one that we're struggling with as well, but I think there's a lot of ways to take it, especially from the health care provider perspective. I think one of them is internally in terms of training health care providers, doctors, clinicians about how to provide kind of empathetic patient-centered care for people experiencing homelessness. Because I think a lot of people, and Kat has mentioned this, there are a lot of people who are very reluctant to come in to get care because of past experiences and there's a lot of wariness of, you know, the medical profession. And then I think that a lot of this obviously is rooted in our housing system, our safety net programs, all of the gaps that we have in those programs. And it took us a long time to get into this, and it's going to take us a long time to get out of it but having that broad coalition that is statewide advocating for more affordable housing, more protections for renters, shoring up the safety net programs, I think can hopefully help make an impact.
Steven Jackson:
So you mentioned some of the reluctance to come in, and we've heard that with different populations, populations of color and just a lot of populations that we've talked about on this podcast and we talk about the concept of trust. Just curious to know from what you guys have heard ears to the ground, what are some of the issues maybe that specifically pertain to the unhoused that maybe perpetuate some of the fear or maybe not even fear, just reluctance to come in to receive medical care. What have you guys heard?
Josh Leopold:
I mean, I think from what I've heard is there's such a power imbalance, right? And so I think a lot of folks when they do come in, they kind of have their backs up to anything that's any kind of perceived slight or sign of disrespect. And so I think there are some things that from the provider perspective, you wouldn't think twice about in terms of policies or language used that somebody who's experiencing homelessness, and we have a consultant program with people with lived experience who talk about this and they still remember appointments from 10 or 15 years ago where someone said something that still makes them upset. So just that sensitivity I think to some of that.
Kat Donnelly:
When people are focused on surviving on the day-to-day, putting things off for a long time in terms of their health is the norm. And so when people come in and someone says to them, why did you wait so long?
Steven Jackson:
Right. It's off-putting.
Kat Donnelly:
It's hard to explain. Because I'm trying to stay alive, because if I leave my tent, my things are stolen, because if I leave my partner, they're vulnerable. If I leave my pet, they're vulnerable. It's hard to explain to someone. So when you talked about education, I really felt that because education of fellow providers I feel like is such a easy harm reduction in this population.
Steven Jackson:
I mean, that's a perfect perspective for our listeners to hear because I'm sure I'm not the only one who has that question. And it's different, but it's not different than a person that would come in and get that same question. And their answer is, well, it's either pay for my diabetes medication or pay for food. You know what I'm saying? I mean, there are just so many populations out there, for lack of better words, where these are decisions that they have to make daily. And it's so easy to be on the other side and say, well, why haven't you come in? I haven't seen you. Your health is failing. This is preventable. And it's like, well live one day in my shoes, and you'll know why. So I'm glad you guys highlighted that perspective because we all need to hear that and learn from that. Dr. Haley, have you had any specific experiences? I know as an ER doc you probably see a lot of people that are unhoused. Anything that stands out in your mind?
Kari Haley:
Yeah, I mean, I think similar to what Kat has seen recently, I mean, we definitely have seen a lot more with frostbite and hypothermia. I think some of the things that really stand out in my mind have often been surrounding wounds as well. Because if you think about it, in your best case scenario, you live in a very nice sterile and house environment. You have no immunocompromised, you have a great diet, and you can heal your wounds super easy, super well, and even then, things don't go well all the time.
But imagine someone who lives in a structure, and there's no control of temperature, there's no control of humidity, there's no control of anything, honestly.
Kat Donnelly:
There's no running water.
Kari Haley:
There's no running water. How do you heal wounds? And people can get really sick from their wounds. They might need an amputation. They can get septic from it. So for me, that's some of the biggest cases in my career that have really stood out is mainly surrounding wounds. And things that you and I would just scrape our knee and call it a day and be like, oh, shucks, darn, that's going to burn for a day or two, can be a really, really big deal for other people.
Steven Jackson:
Yeah. Well, we're just very thankful for you guys and the work that you do. I've definitely been educated, should I say, I've increased my education. There's so much I don't know, of course, and so much to learn, but we're just so appreciative of the unhoused being cared for and again, their needs being met or at least being addressed. And I'm just hoping that those that are listening will join forces with you in the way that they can to help because it sounds like there's a lot of work to do. Are there any particular websites or anything that people can reference or any ways to volunteer that people are able to do? Anything that stands out?
Josh Leopold:
Well, we have a website in terms of education. At the Minnesota Department of Health, we have a website on public health and homelessness that has a lot of the resources I mentioned, like our homeless mortality study. I recommend in terms of websites, there's the Minnesota Coalition for the Homeless has a good website in terms of advocacy opportunities for people. And then the Minnesota Interagency Council on Homelessness has a good website with different resources as well.
Kat Donnelly:
Yeah, I would add National Health Care for the Homeless Council and the Street Medicine Institute.
Kari Haley:
Those are all really good things. So again, thank you so much. I feel like we could talk on this topic for much longer, but I think it's really good. We talk about equity inclusion on our podcast. That's the bare minimum. And really, I think getting people to hear more about the unhoused population or the sheltered and unsheltered population and putting that into that equity and inclusivity statements, I think is really, really important because I think that this patient population is oftentimes not thought about within that space. So I'm so glad that you guys are here to talk to us more about it and really appreciate your time.
Kat Donnelly:
Thank you for the invitation.
Josh Leopold:
Yeah, thank you for having us.
Steven Jackson:
Thank you, guys. "Off the Charts" is a production of Health Partners and Park Nicollet.
Kari Haley:
It is recorded by Jimmy Bellamy, with creative by Peggy Arnson, Tina Long, Tim Myers and Jeff Jondahl.
Steven Jackson:
Production services provided by Matriarch Digital Media.
Kari Haley:
Our theme music is by Ryan Ike.