Gaeta examines a homeless patient at a Boston Health Care for the Homeless Program clinic in Boston.

Enhancing Healthcare for Boston's Homeless

Ever since becoming a physician 12 years ago, Jessie M. Gaeta’s work has focused on society’s hard luck cases. Her patients are addicted to drugs, have been sexually abused, or suffer from mental illness. They are tragic cases of people sleeping under highway bridges, in abandoned houses and in crowded shelters. They live in poverty, despair, and some on the brink of death.

Gaeta’s patients are typically men who die at an average age of 47. They are the most chronic homeless in Boston. “These are unspeakable life stories that we are witnessing,” says Gaeta, a 1998 graduate. “It is devastating.”

Gaeta, age 37, co-founded Home & Healthy for Good’s Housing First program, operated under the auspices of the Massachusetts Housing and Shelter Alliance where she is a physician advocate. The program’s mission, while unconventional, is to find permanent housing first for the chronic homeless and then treat their illnesses.

Since its launch in 2005, Housing First has seen strong results and has not only saved the state thousands of dollars in hospital and emergency care bills per patient, but has kept many chronic homeless off the streets. Of the 400 homeless patients in the program, 86 percent continue to maintain their residence, reports Gaeta, who is also medical director at the Barbara McInnis House of Boston Health Care for the Homeless Program.

Gaeta says that the average cost per person in the program has fallen nearly four fold to $8,500 a year from $33,000. It has been so successful that the state has doubled to $1.2 million its funding for the project. “It has had this tremendous impact on people throughout the state,” Gaeta says. “A lot of people predicted this was never going to work.”

Chronic homelessness is a drain on medical systems across the country. In Massachusetts alone there are about 15,000 homeless with nearly half in Boston. The most costly are the chronic homeless or people who have lived on the street for extended periods of time and have a disability. They represent about 10 percent of the homeless and consume more than half the resources.

Data collected by James O’Connell, MD, founder of the Boston Health Care for the Homeless Program, revealed that 119 street dwellers accounted for 18,384 emergency room visits and 871 medical hospitalizations over a five-year period. The average annual health care cost for individuals living on the street was $28,436 compared to $6,056 for individuals who obtained housing, according to the study.

You would think that this group of people would have high instances of hypothermia, frostbite and TB,” Gaeta says. “But what homeless people are suffering and dying from is cancer, heart disease and high blood pressure.”

These diseases appear in the homeless roughly 20 years ahead of the general population, according to Gaeta. The homeless she works with have complicated medical histories, and their mortality rate is five times higher than the general population.
States have traditionally dealt with the homeless by moving them into shelters or emergency housing with other homeless. Once sheltered, they are treated for their addictions and mental illnesses. If all works out, they are moved into transitional housing. But administering medication on a consistent basis with homeless patients is challenging.

“I grew increasingly frustrated with the trouble I was having trying to treat chronic illness in this (shelter) setting,” Gaeta says. “I felt it was just patchwork to prescribe insulin to a diabetic patient who was living in a shelter. I was really having a hard time managing chronic disease.”

Her program takes the old model and stands it on its head, Gaeta says. Housing, she says, is the foundation upon which everything else is built upon. If people don’t have a home they cannot rest and heal properly; they have no place to keep food or medication, and they are at risk of theft and violence. In this program, tenants live in independent apartments that are leased, or group homes within communities. The program couples housing with services in the home. A case manager links the tenant to mainstream service, such as mental health, health care, substance abuse and vocational and life skills training.

It seems natural that Gaeta was involved in creating a program like Housing First. As a teenager, she recognized the link between income and healthcare. An only child, Gaeta grew up in a middle class family in Gaithersburg, Md. Her father was a photo journalist, and her mother a high school teacher. While the family had health insurance, the deductibles and co-pays were so high they squeezed the family’s budget. “Even as a teenager I remember thinking about this connection between employment and one’s ability to have health insurance,” she recalls.

She was also influenced by her grandfather, a Rotarian, who was not only a Boys & Girls Clubs of America volunteer, but developed a scholarship fund for disadvantaged youth, and played Santa Claus at an orphanage. Her sensitivity to health care affordability and to helping the less fortunate carried through into college where she worked as a volunteer for Habitat for Humanity. One weekend she helped build a home for a homeless family. “I got active with the homeless around that age,” she says.

During medical school she worked with the Medical Alumni Association on Project Feast, which serves Thanksgiving dinner to hundreds each year at the Booker T. Washington Middle School. She also helped provide healthcare to the homeless and organized volunteer projects. During her fourth year she worked as a “street doctor” in New York City. “I completely fell in love with the work,” she says. “I figured out that this was exactly what I wanted to do.”

After receiving a medical degree, Gaeta attended the Boston University Medical Center for internship and residency training in internal medicine. She continued her efforts to help the homeless, staffing shelters that provided healthcare. In 2001, she was named chief resident of internal medicine, and by 2005, Gaeta became physician advocate for the Massachusetts Housing and Shelter Alliance, an advocacy group. In 2009, she was named medical director of the Barbara McInnis House of Boston Health Care for the Homeless Program, a 104-bed medical respite facility that provides 24-hour medical care to homeless people.

Gaeta, who is married and has two young children, has trained herself to leave her work on the streets or in the hospital. “We see severe mental illness. We see social isolation from family, violence, extreme poverty and hunger,” she says. “This is hard work. It is harder than any other kind of medical practice. The relationships are more intense.”

But in the face of such despair, Gaeta hopes her work in the streets, hospitals, shelters and statehouse help the people most Americans would rather forget. “I am in love with my job,” Gaeta says. “And I am optimistic.”