Project for Psychiatric Outreach to the Homeless.

In New York, I worked for an orga­ni­za­tion called Project for Psy­chi­atric Out­reach to the Home­less (PPOH). It has a hum­ble his­tory: Over 20 years ago, a group of psy­chi­a­trists were sit­ting around and dis­cussing the need for psy­chi­atric ser­vices for the home­less. They decided to vol­un­teer their time and skills to this population.

The orga­ni­za­tion grew and, for both admin­is­tra­tive and finan­cial rea­sons, even­tu­ally became part of another social ser­vice orga­ni­za­tion, CUCS. At this point, PPOH serves more for­merly home­less indi­vid­u­als than peo­ple who are cur­rently homeless.

PPOH is not a big out­fit. By the time I left, there were about 12 full-time psy­chi­a­trists, sev­eral part-time and per diem psy­chi­a­trists, and a hand­ful of psy­chi­atric res­i­dents. As a group, we worked at nearly 60 sites in three bor­oughs of New York City.

The job is atyp­i­cal in many ways. PPOH psy­chi­a­trists are paired with dif­fer­ent social ser­vice agen­cies to pro­vide psy­chi­atric ser­vices. The ratio­nale is that social ser­vice agen­cies often don’t have the resources to employ psy­chi­a­trists. Fur­ther­more, these agen­cies often do not know how to pro­vide the sup­port and super­vi­sion to psy­chi­a­trists. What they do have, how­ever, are patients who would ben­e­fit from psy­chi­atric ser­vices, but the patients either can­not or will not visit a psy­chi­a­trist in a clinic or other typ­i­cal setting.

Thus, PPOH brings psy­chi­a­trists to the patients.

Fund­ing for PPOH dif­fers from fund­ing for “main­stream” psy­chi­atric ser­vices. PPOH receives fund­ing from state and city agen­cies (gov­ern­ment money), grants (from orga­ni­za­tions like Robin Hood and van Amerin­gen), and fees from the social ser­vice agen­cies them­selves. These fees are usu­ally lower than what it would cost to hire a per diem psy­chi­a­trist directly.

Because PPOH did not receive money from Med­ic­aid, it did not have to fol­low Med­ic­aid rules and reg­u­la­tions. (PPOH would not be able to ful­fill its mis­sion if it did accept Med­ic­aid funds, as Med­ic­aid has require­ments that physi­cians see patients in a phys­i­cal loca­tions des­ig­nated as clin­ics. This con­tra­dicts the organization’s mis­sion. While at PPOH, I often saw patients on side­walks under scaf­fold­ing, in their apart­ments, etc.)

I was one of the few psy­chi­a­trists in the group who worked with an agency who worked with Med­ic­aid, though because of the nature of the pro­gram (an Assertive Com­mu­nity Treat­ment pro­gram; more on that later), the reg­u­la­tions had lit­tle effect on my actual clin­i­cal work. It did influ­ence the doc­u­men­ta­tion I had to provide.

PPOH does not have any con­tracts with insur­ance com­pa­nies (as the tar­get pop­u­la­tion often did not have tra­di­tional insur­ance), which also means that there were no nego­ti­a­tions about reim­burse­ment rates or dis­cus­sions about con­ces­sions to have access to the patients on an insur­ance panel.

Thus, I essen­tially had a job out­side of the US health­care sys­tem, which, in many ways, was appro­pri­ate: The pop­u­la­tion I worked with was also gen­er­ally out­side of the US health­care sys­tem. Despite this, we often viewed our­selves as “hot spot­ters”, as a few of our patients often crossed into the US health care sys­tem through ERs and hospitals.

Because of this fund­ing struc­ture, I worked as a salaried employee. There were no pro­duc­tiv­ity expec­ta­tions or bonuses. While this arrange­ment can result in peo­ple slack­ing off, my boss chose his employ­ees care­fully to pre­vent this problem.

Psy­chi­a­trists who choose to work at PPOH, how­ever, do not work there for the money. The median salary for a psy­chi­a­trist in New York is appar­ently $228,815. Dur­ing my time at PPOH, over 90% of psy­chi­a­trists in New York earned more money than me.

(Yes, the specter of stu­dent loans con­tin­ues to haunt me and, of course, it would be nice to make more money, but let’s be hon­est: I was earn­ing enough money to live com­fort­ably in New York. Not every­one who lives there can say that.)

In exchange, I had the time and oppor­tu­nity to work with those who often do not receive care. Many of these indi­vid­u­als had sig­nif­i­cant psy­chi­atric con­di­tions that con­tributed to their lack of employ­ment, home­less­ness, and poverty. I had more con­trol over how often and how long I got to see patients. Patients had eas­ier access to me and I had the flex­i­bil­ity in my sched­ule for urgent appointments.

The ide­al­ist in me finds the fis­cal real­i­ties of health care demor­al­iz­ing. I don’t like think­ing about how eco­nom­ics affects the rela­tion­ships I have with patients. I didn’t go into med­i­cine to think about that stuff. How­ever, I do firmly believe that physi­cians should have a basic under­stand­ing of their clinic or depart­ment bud­gets. Form fol­lows func­tion. And form fol­lows funds.

Next: What my job at PPOH actu­ally looked like.