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Homeless, housed, and homeless again

Jill Roncarati, PA-C, MPH, with Vickie Ritterband

Jill Roncarati works as a PA with the Boston Health Care for the Homeless Program, Boston, Massachusetts. Vickie Ritterband is the media coordinator for the organization. They have indicated no relationships to disclose relating to the content of this article.

My patient “Bill” is a 59-year-old Vietnam veteran who has lived on the streets of Boston for many years. He suffers from chronic alcohol abuse, has never married, and has no kids. Bill doesn’t talk a lot about his past, but he did tell me that he was hit by a car as a young child and suffered a brain injury. During baseball season, Bill lives near Fenway Park, where the panhandling can be fairly rewarding. When the weather gets frigid, he heads northeast to an alley between Newbury and Boylston Streets. He sleeps next to a blower that emits warm air from a building.

Bill is smart, articulate, and insightful. A more recent traumatic head injury has left him with a seizure disorder that makes him vulnerable to falls and additional head trauma. He’s about 6 feet tall, with a weathered face, shaggy brown hair, and often a beard. He loves to talk and is an avid reader. You’ll often find him with his head buried in a book or in the sports page of the Boston Herald.

In January 2007, we thought Bill’s homeless days had finally come to an end. An innovative program called Housing First moved him into a rooming house where he shared a kitchen and bathroom with 20 other people. It was the first time in two decades that he slept in a bed, made his own meals, and had a telephone number. Unfortunately, within 7 months, he was back on the street.

Bill’s story is not a cautionary tale about the pull of the streets or the failure of a program. This is a story of one man’s struggle to find the right place to hang his hat.

Housing First turns the traditional model of housing the homeless on its head; its method is to “give people a home first, then work on getting them sober, drug-free, employed, and psychiatrically stable.” Although controversial, the idea is gaining traction throughout the country.

To qualify for the program, a person has to have lived on the streets for at least 6 months and meet medical criteria that indicate they are at high risk for mortality, including the tri-morbidity of substance abuse, severe and persistent mental illness, and multiple chronic medical illnesses. As a member of the Boston Health Care for the Homeless Program’s Street Team, I am deeply involved with the project. The Street Team takes care of people who live on the streets, on park benches, under bridges, and in back alleyways. We also assist them with the difficult transition from the streets to a home, continuing to provide health care and mental health support as they contend with the challenges of living independently.

Those challenges can be very daunting to our patients, and Bill was no exception. But what impressed me was Bill’s eloquent attitude. Although there were people to help him with tasks like grocery shopping, he was determined to tackle these responsibilities alone. Bill was very proud of his new home and kept it neat and clean.

He stayed sober for months. Once a week, I would visit to review his medications, listen to his heart and lungs, and check his feet, which have seen their share of misery. We talked every other day by phone.

But slowly, things began to unravel. A good friend died, and a man in the rooming house hanged himself. Bill’s room was near a noisy porch where people gathered to smoke, and he found this disruptive. Bill started drinking again. He would have loud outbursts that eventually landed him in Housing Court. Bill was ordered to attend a detoxification program but left before completing it. He decided that the rooming house was the wrong place for him and handed in his key.

Now Bill is back on the street, but eager to try again. Next time, he wants to live in his own apartment. I continue to take care of Bill’s health care needs, and I am supportive of his decision to give up his room. Although I was disappointed, I was very proud of him that he understood his needs.

Bill’s decision shouldn’t have surprised me. In one of my most vivid memories of his brief time in the rooming house, after helping Bill move into his room, a caseworker and I arranged the furniture, made the bed, and helped Bill hang up his clothes. When I visited a few days later, Bill had rearranged everything. And his layout was far better!

Postscript: Bill recently moved into a studio apartment. He has been sober for almost 6 months, and he enjoys hunting for bargains to furnish his new home. JAAPA