The National Low Income Housing Coalition estimates that a Tennessee resident earning minimum wage—$7.25 an hour—would have to work 67 hours a week in order to afford a modest one-bedroom apartment in The Volunteer State.

It’s even worse in the capital city of Nashville.  There, the NLIHC notes, today’s average market rents require earnings of $12.14 an hour for a one-bedroom flat, or $17.99 an hour for a two-bedroom.

Needless to say, this has caused a crisis for low-income renters. The result? A spike in homelessness.  Thanks to near-constant development, neighborhood gentrification, a dearth of low-income housing construction, and weak rent protection laws, last year an estimated 2,154 Nashville residents—both individuals and families—were “without domicile.”  Nearly a quarter of them, 470 adults, live on city streets rather than in emergency shelters or transitional housing.

Dr. Sheryl B. Fleisch, a 34-year-old psychiatrist, founded the Street Psychiatry and Homeless Health Services Program at Vanderbilt University Medical Center in 2014. Since then, once a week she and the program staffers who join her wander the city offering care to women and men living in parks, tunnels, and under bridges and highway underpasses. Thanks to a small grant, Fleisch and her colleagues dispense kind words along with supplies: bus vouchers, granola bars, socks, sweatpants, tarps, tents, underwear, and water. They also provide both psychiatric and medical treatment for those who want it, something that has dramatically reduced emergency room visits and hospital stays for Nashville’s homeless.

Last year the program received the Model Project Award from the National Alliance on Mental Illness; Fleisch herself has also been widely lauded. She spoke to Eleanor J. Bader via email and stressed the importance of listening to her patients and treating them with respect, dignity, and entitlement.

EJB: What drew you to psychiatry in the first place?

SBF: I always thought I would be an orthopedic surgeon. I love sports. I appreciate the concept of having a problem, an injury, and then fixing it. As I went on in my training, though, I realized that there are so many people for whom problems cannot be easily fixed, where it takes time, creativity, and trust to build a relationship that can result in important healing.

EJB: Most people walk by the homeless as if they are invisible or toss some change or a few dollars their way. What motivated you to try to engage folks living on the streets? When was this? Was there a particular precipitating event where something clicked and you decided to do something concrete to help?

SBF: There was no specific click; rather, it was more a series of events. Medical students at Vanderbilt—I graduated from Vanderbilt Medical School in 2008—are trained in rigorous, evidence-based medicine. But interestingly, there is still a huge disconnect between the patient, the provider, and the system of care.  When a patient says that he or she cannot afford a medication, and we prescribe that drug anyway because we know that it is the ‘best’ medication, there is a gap. Patients feel that they are not being heard and providers feel as if patients are not following-up with their care. No one wins. It was obvious that we needed to figure out an alternative model to encourage individuals to disrupt the cycle that was happening each day in the hospital.

I’ve discovered that if we meet people where they are, in their environment, and provide active follow-up care, we can meet the needs of both the system and the patient.

EJB: Please talk about your partners in the Street Psychiatry Program, both community-based and medical. How does the team coordinate its outreach and treatment efforts?

SBF: We partner with a local non-profit called Park Center, a program that provides a variety of resources to individuals struggling with mental illness and homelessness. We also work with multiple other non-profit organizations in Nashville.

Our street team consists of me and three psychiatry residents who participate in a year-long rotation as part of their residency training program.  We go out every Wednesday and are accompanied by a Park Center outreach worker. I arrange all of the appointments and we have a more than 95 percent show rate. Our goal is to provide psychiatric and basic medical care to Nashville’s unsheltered homeless population.

We also provide some non-perishable food items, clothing, and hygiene products to our patients. We’ve obtained these items thanks to a grant from the Tennessee Health Foundation through the Park Center.

EJB: Is medication for psychiatric conditions dispensed on the street or do people have to visit the hospital for a more thorough screening? Do the homeless patients who you see on the street ever come into the hospital?

SBF: We dispense medication through our mobile pharmacy, which has been provided to us through the Vanderbilt Psychiatric Hospital.  We request psychotropic and basic medical medications and we dispense them like any other pharmacy would. We log them in a book and return the bag to our pharmacy the next day. We complete this process weekly.

There are many individuals whom we know from both the hospital and the streets. This is what makes our program so unique. When people come into the hospital, we see them in our consultation service and then continue to follow them if they go back onto the streets. We can also refer them to our own housing navigator and disability coordinator should the individual qualify.

EJB: Since medical problems often accompany living outdoors—things like respiratory infections and leg ulcers, for example—how are these treated?

SBF: If we perceive a situation as emergent, we will recommend that the person come into the hospital. Usually, this would be done when we see a large infection that cannot be treated on the street, or in cases of frostbite or gangrene. Otherwise, we are generally able to treat most infections, bug bites, and other primary care conditions that individuals on the street may have.

EJB: Do you ever talk to people on the streets about moving indoors? Can you walk me through a typical encounter where this is raised?

SBF: Yes, we frequently talk about the preference of staying out versus moving inside. It isn’t so easy though. The average market rent in Nashville is more than $1000 a month. Many individuals who are homeless work at minimum wage jobs, earning $1250 a month, or receive Social Security Disability or Supplemental Security Income [SSI] of about $733 a month. This is clearly not enough to enable them to afford housing in this area. Even if someone wants to move inside, the process is long and complicated. In my experience more than 90 percent of the people who are homeless would prefer to live indoors, but are unable to navigate the financial, legal and other barriers.

EJB: Does a discussion of sobriety ever enter into your interactions with your patients? How often is substance abuse an issue for the people you treat?

SBF: Frequently. There is an approximately 80 percent prevalence of substance use disorders in individuals who are homeless. Many of the people we meet are actively using. We do not push them. The individuals we meet are already on the outskirts of society, and we need to gain their trust. Just today, though, someone I’ve known for two years decided to voluntarily enter detox. This was the amount of time he needed, and it was important for him to make the move himself.

EJB: How has the city of Nashville responded to the Street Psychiatry program? In some locales, it is illegal to create encampments. What is Nashville’s policy? Is the City’s Health Department on board?

SBF: We are the first physicians in Nashville—and in Tennessee, more generally—to go out on the street and provide psychiatric and/or medical care.  We have had an overwhelmingly positive response to the program from the city. The community at-large has also been gracious.

Our services are mostly spread by word of mouth via homeless persons. Still, all encampments in Nashville are illegal with the exception of one located on church property. The Mayor’s office is currently determining what efforts will be necessary to assist with more affordable housing. This is a major need in the city.

EJB: Does the Street Psychiatry Program ever engage in overt advocacy? That is, does the program get involved in policy work to, say, halt evictions, fight gentrification, roll back rents, or create more affordable housing?

SBF: Our clinical work is our advocacy. By becoming well-respected in the community and by showing evidence-based data to prove that this work is needed –and that it can make measurable changes on a hospital system—we will be able to show the city that we need improved winter shelter resources and more affordable housing.

EJB: What is the most gratifying part of this work?

SBF: We see people who literally have nothing. They carry every belonging they own in a small plastic bag. Yet, when we see them, they always know us by name, offer us a place to sit, a smile, and a hug when we leave. I have never seen gratitude quite like this.

EJB: What is the least gratifying?

SBF: In truth, it is devastating that we have predictable problems—homelessness, addiction, poverty—and that we have been unable to come up with a country-wide solution to them. Even when individuals strongly desire to obtain housing or addiction treatment, there is barrier after barrier. Being homeless is not easy and getting out of it is much harder than it may appear.

EJB: Does being Jewish having anything to do with your determination to do this work? Is this Tikkun Olam?

SBF: I think we are always taught growing up that we are not only responsible for doing good for ourselves, but that we should do good for others. I don’t believe this was a conscious thought on my part, but I believe that this is embedded in our culture.

EJB: Is there anything else you’d like to say about the Street Psychiatry Program or the problem of homelessness in Nashville or beyond?

SBF: Although the city of Nashville has done a survey of homeless people, it was done on a single night and the numbers are a gross underestimation of the problem. It’s likely that the estimate is half the real total.  A lot of people are also unstably housed, moving from place to place, going from friend to friend, and are not counted as homeless even though they don’t have a permanent address.