Case Study: A Lesson in Trust and the Back Story—Untreated Mental Illness, Addiction, Skin Condition and Tooth Decay

The purpose of the following case study is to understand how the guidelines are applied in real life situations. Group discussion of patient stories often generate new ideas and illustrate how evidenced-based practices are used, including how different aspects of a person’s life are inter-related.

History

• Joey is a 55-year-old man, a gentle and shy loner with paucity of speech and poor eye contact. He appears to be fearful of others and dresses flamboyantly with a very thin physique.
• He has lived unsheltered around the perimeter of a local hospital for 15 years.
• He has been one of the city’s highest utilizers of the crisis health system with over 50 hospital visits annually for 3 consecutive years.
• Joey self-medicated for many years with daily alcohol and heroin use.

Working Diagnosis

• Schizoaffective disorder, alcohol and heroin use disorders, dental disease

Patient’s Presenting Problem

• Itchy skin (presenting problem at the ER)
• “I need to get my rotten teeth fixed.” (told to Venice Family Clinic doctor)

Management of Case

For 3 years the outreach team of The People Concern tried unsuccessfully to engage Joey in weekly outreach visits in the vicinity of the hospital where he most often could be found. He would ignore team members when he was approached and run away and hide.

The ER staff persistently attempted warm handoffs to the street outreach team, to no avail. The outreach team thought to ask a hospital administrator for help in identifying anyone Joey trusted. In response to this question, the entire hospital staff from the cafeteria worker to the administrator identified the same hospital security guard as that person.

The outreach team asked the security guard to introduce them to Joey. Instead, the guard suggested a better approach—that he be the person to accompany Joey and drive him to a first intake appointment at the clinic located at the homeless service agency. Joey agreed to this offer on the condition that his ally the guard accompany him for the visit.

The outreach team and guard agreed, and so did Joey, provided that the guard transport and accompany Joey as well as sit with him for the whole encounter.

At the first visit, Joey’s entire demeanor changed. He was cooperative in the guard’s presence. Joey opened up with information about his current situation and history.

VFC Street Medicine Team then arranged for a dentist to address Joey’s primary concern which was the pain he was experiencing from severe tooth decay. Soon after, Joey began to inquire about housing, which took over six months to secure. By this time, he was coming to scheduled appointments on his own.

After consents were signed, a hospital nurse who had frequently seen Joey asking for food in the cafeteria, decided to treat him to coffee. While both stood in line, she observed a cafeteria worker give a disparaging look to Joey. The staff suspected Joey had an underlying mental illness, but he had never acknowledged or shared this with anyone. The nurse took the risk to use this reaction as an opportunity to engage Joey directly.

Nurse: “Our hospital is a bit schizophrenic sometimes and not always so nice.” At which point, Joey’s face lit up.

Joey: “That’s what I am too, schizophrenic!”

And he proceeded to share his story.

Joey: “One day when I was 20, the lights just went out, and never seemed to come back on. I didn’t understand what was happening to me, but I knew I was different from then on and that was the moment that everything changed. I was so scared and felt such shame, I didn’t know what to do, so I left my home and my family in the Midwest and traveled to Los Angeles and I have not been back since.”

Resolution

After this encounter, Joey further let down his guard. Two weeks after moving into his apartment, someone broke into Joey’s unit and stole his new TV. He was terrified and quickly abandoned his apartment. Joey returned to sleeping around the hospital perimeter, where he felt safe under the watchful eye of the security guard.

At this point, Joey was willing to explore the possibility of family reunification, suggested by staff. With his permission, Joey’s case manager tracked down his sister who had become a psychiatric nurse. She was overjoyed to learn that Joey was alive and invited him to come live with her. Joey did not even know he was missed.

The outreach team arranged for Joey’s transportation. He moved into his sister’s home who now lovingly cares for him.

Questions:

• What event(s) in Joey’s life may have created his path into homelessness?
• What were some of the barriers Joey faced in accessing health care?
• Why do you think the hospital emergency department was the first place Joey thought to go for care? How might the emergency department improve care for patients like Joey?
• Why do you think Joey would not make eye contact and hide from the team initially? How would you build a trusting relationship with a person like Joey?
• What aspects of the team’s care do you think represent high-quality care for people experiencing homelessness? How do you think the hospital nurse made Joey feel like he was a “real person?”
• What are the major lessons learned from the story? How does this reflect what you are seeing on your Street Medicine Rotation?

Themes and Lessons Learned

Build trust and find out the back story: Trust building is a long and persistent process. The sooner you gain a person’s trust, the quicker you can learn a person’s back story, and the faster and more effective the engagement process. Warm handoffs based upon trust are key. Careful sleuthing to find the unsuspecting trusted source (in this case, the hospital security guard) can pay great dividends in time saved and trust-building.

Rely on a broad definition of The Team: Any trusted person as defined by the patient who accepts the person unconditionally with no judgement should be engaged in carrying out a warm handoff or a successful intervention.

Supportive Housing is not for everyone: Having never lived on his own before, Joey left home at the first onset of mental illness and remained unhoused for over thirty years. He lacked the necessary skills and experience to live independently in his own apartment. He was scared and unprepared to live independently in an apartment.

Obstacles are opportunities for creative solutions – such as family reunification: Joey abandoned his apartment and refused to consider living in another apartment. While often not an obvious choice, family reunification should be explored as a possible option for housing. Sometimes it is the best option. Many individuals with histories of homelessness have lost their identity with no knowledge that they are “missing” to their families.

Safety First: Safety was the most important precondition for Joey’s living situation. He followed his instincts and lived around the perimeter of the hospital where he felt safe. And the prospect of returning home to a caring family member gave Joey an increased feeling of safety and security.