Kate Gleason-Bachman: “The work itself is not hard”

At Pathways to Housing PA, we use the Housing First model, which means that we provide housing to people first, with no preconditions. We see housing as a human right. People receive housing regardless of their substance use or mental health status. We see that as a first step in helping people reintegrate into the […]

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At Pathways to Housing PA, we use the Housing First model, which means that we provide housing to people first, with no preconditions. We see housing as a human right. People receive housing regardless of their substance use or mental health status. We see that as a first step in helping people reintegrate into the community and recover from any number of things, including substance use.

As a part of my series about “Heroes Of The Addiction Crisis” I had the pleasure of interviewing Kate Gleason-Bachman.

Kate Gleason-Bachman, RN BSN, is a Philadelphia-based nurse who has worked in community health for the past twelve years. Her nursing career has been focused on serving people experiencing homelessness and her current interest areas include substance use disorders, medication assisted treatment, food access and nutrition, and wound care. Kate currently serves as the Director of Nursing at Pathways to Housing PA, and has extensive experience specifically serving individuals with opioid use disorder.

Thank you so much for doing this with us! Can you tell us a bit of your backstory?

Istarted with a degree in Sociology and my first job was in Public Health research. I ended up as a consultant for a nonprofit in Washington, DC working with Federally Qualified Health Centers that provided services for farm workers. I traveled all over the country to rural areas, meeting with programs, and learning about how they conducted outreach to farm workers. A lot of those programs were run by nurses and nurse practitioners. I had been feeling really distant from working more directly with people and this seemed like a great way to provide direct care and be more involved in peoples’ lives.

So I decided to go back to school to become a nurse. It took a few years to do all the prerequisites and, during that time, I worked in a consultant capacity for an organization working with people experiencing homelessness in New York City. I went to Columbia Nursing School and, upon graduation, moved back to Philadelphia, PA. I worked in one of the large hospitals here in Philly and had a terrible experience. It was shocking to be a part of the U.S. healthcare system and to see how poorly it functioned for people — how poorly their needs were met, how insurance drove everything that was done, and despite all the service providers I was working with (doctors, nurses, therapists, social workers), and our attempts to meet people’s needs, there was still barrier after barrier. It was a really toxic setting and I felt like I had made the biggest mistake of my life by becoming a nurse. It was really, really shocking to me.

I ended up going back to work for the first nonprofit I had ever worked for, back when I was doing public health research, which was Public Health Management Corporation (PHMC). I became a nurse in the city shelter system, which was a program that PHMC ran. That was kind of how I found my way into advocacy and community health nursing, and that was clearly where I should have been all along. It took me some time to figure out that that was my place in nursing.

I worked for three years in the city shelter system, going to a different shelter every day and being the only clinical provider on site. I did a lot of triage and re-entry to care. From there, I went to a Federally Qualified Health Center in Philly called the Mary Howard Health Center, which serves only people experiencing homelessness. I was there for several years before I ultimately came to Pathways to Housing PA, where I am now the Director of Nursing.

Since becoming a nurse, I’ve mostly worked with people experiencing homelessness and that has really been the place where I’ve found my heart and my passion. Being in the community working with people has been the best for me and the best way for me to help navigate those problems I first experienced in the health system.

Is there a particular story or incident that inspired you to get involved in your work with opioid and drug addiction?

There actually isn’t. My work had primarily been with people experiencing homelessness, but I happened to get a job on one of the opioid use disorder teams when I came to Pathways. I was excited by that, but it wasn’t what I was seeking out at the time. Having this position allowed me to learn more about the lives of our participants and the impact of substance use. In retrospect, I realized how much substance use had been affecting many of the people I had worked with for years to a degree that I did not recognize. I talked with people about substance use and there were people that I supported through opioid use disorder and its challenges, but I think I was barely scratching the surface in my previous work in terms of how much of people’s lives were being impacted by a substance use disorder. Coming to Pathways and being invited into my patients’ world, I now better understand how people are really living their lives and how substance use impacts them. I do feel really lucky to have found this work and it has certainly become a passion of mine.

Can you explain what brought us to this place? Where did this epidemic come from?

I’ve done a lot of research on this topic and I think it’s generally accepted that the opioid crisis in the United States has come together as kind of a perfect storm of events. Part of what happened was a shift in the 1990s to pain being considered as the fifth vital sign. We used to check for temperature, blood pressure, heart rate, oxygen, and we ended up also checking for pain. That became this important thing to always ask people. A focus then came in to address pain, and that’s not wrong, but at the same time, drug makers started coming out with these long-acting opioids like OxyContin that were marketed as non-addictive. They were, of course, very quickly shown to be addictive, but the intense marketing that targeted providers with a lot of Medicaid patients, and providers in rural areas, continued as though that were not the case. The marketing did not catch up with the research, purposely.

So, these drugs were marketed as not being dangerous although they truly were, and as providers are asking this fifth vital sign question, “Are you having pain?” they started to provide these drugs more and more. We then saw, in a lot of places where folks were rather opioid naïve, that there was a flood of pills in places where a heroin problem had already existed, like Philadelphia. So as more pills came into the picture, there was a shift in the drug trade coming from Mexico. Heroin became cheap in a wide swath of the United States where it had not been previously accessible, and a lot of folks who had become addicted to OxyContin from a provider switched over to using heroin when they could no longer afford it.

Unfortunately, Philadelphia has always had a heroin trade. We’ve been known for having the purest heroin in the country. Sometime after the year 2000, a study was done that actually showed that Philadelphia did, in fact, have the purest heroin of all the cities tested.

Since that time, we’ve seen the synthetic opioid, Fentanyl, come into our drug supply. It can be easy to transport across borders because the quantities used are extremely small. It’s easy to hide and get into the United States, even by mail. As a result, the supply in Philadelphia has been cut with Fentanyl and we’ve seen a huge increase in overdoses since that has happened. Now, Philadelphia is known for having a huge amount of Fentanyl in the drug supply and that’s something that people also seek out, and it’s quite dangerous in terms of overdose.

Can you describe how your work is making an impact battling this epidemic?

At Pathways to Housing PA, we use the Housing First model, which means that we provide housing to people first, with no preconditions. We see housing as a human right. People receive housing regardless of their substance use or mental health status. We see that as a first step in helping people reintegrate into the community and recover from any number of things, including substance use.

We also utilize a harm reduction approach, meaning we really meet people where they are. I think that is a key in how we can impact the epidemic. If you talk with people in Kensington, which is the neighborhood where we have the most opioid use, almost 100% of them would tell you they do not want to be doing what they are doing. They do not want to continue using. It’s not a fun life. They’re not enjoying it. Their relationships have been impacted, their families have been impacted, and they don’t have their children living with them. They’re really suffering, and they want to change, but it’s very, very challenging. We are able, through our services, to meet people literally where they are, even if it’s on a street corner. The nurse, social worker, peer specialist, or whoever is meeting with them, is there with them in their neighborhood. We give folks a place to live and then provide services for them in the way that helps them feel like they can move forward.

People talk about recovery as not being a straight line and it really isn’t. I think it makes a huge difference to people that we remain present with them through that process, which includes relapses, failures, and frustration. We walk with them through that process and we’re there for them.

Wow! Without sharing real names, can you tell us a story about a particular individual who was impacted by your initiative?

A lot of stories come up when I think about our work and the way that we’ve impacted people’s lives in both small and big ways. But there’s one person in particular who I always think of. When we met, I had only been working here for a few months and now I’ve been here for about 3 ½ years.

She was a new participant and had just gotten housed. I was the nurse on the team and I got a call from this woman, whom I had not yet met, saying she was in her apartment, her legs were swollen, she couldn’t walk, and she couldn’t use her arm. So I went to go see her. She had moved to a neighborhood pretty far away from Kensington, but then she kind of got trapped in her apartment because she had no way to travel. She was in withdrawal, her legs were very, very swollen, and she could not use her arm. It was highly concerning. I assessed her and determined she really needed to go to the emergency room.

And so we began the longest journey. We first had to go get money from someone who lived off the Boulevard in the Northeast and we didn’t know what the address was, so we just kind of had to find the house based on what she remembered it to look like. So we drove around to find this house, which eventually we do, and luckily it is her friend’s and she’s able to borrow 10 dollars. We then drive to Kensington and I drop her on a street corner so she could get well. We made a plan to meet back up at another street corner shortly thereafter. So she does what she has to do and we meet back up. She gets back in the car and is feeling much better but now we need to go to her sister’s house. So we drive to her sister’s, where she needs to visit her cat and pick up a few medications. Finally, it’s the end of the day. We arrive at the hospital and we’re in the parking lot and she says, “I don’t know about this. It’s been a long day and maybe we just pack it in and go home.” I said, “Nope! We made it this far. We gotta go inside. This has to happen.” So we go in together and they immediately begin assessing all these things that are going on with her physically. This is the end of the day, and I have to leave, and she stays there. She didn’t know where she was in the city. It was a neighborhood she was not familiar with, and she was nervous to leave, so that is what made her stay overnight.

The hospital staff found out this woman had new onset congestive heart failure. She had a broken arm from a fall about two weeks prior that had not been set — all these things. So they admitted her and she was to be there for several days. The hospital didn’t have Suboxone or buprenorphine on their formulary at the time. We worked with the medical team there and our physician from Project Home, who was willing to write the prescription for Suboxone, which we actually brought to this woman in the hospital, which the hospital administered. This is what she wanted. She wanted to stop using and get on Suboxone, but it’s so difficult for people to do that in the community. Sometimes, when you have a bit of a pause, like a hospital admission, it can be a good opportunity for people to take a breath and actually try to see if it will work for them.

I think she actually had some precipitated withdrawal while in the hospital, but was able to kind of ride it out and continue the Suboxone, which she still takes today. That episode was what allowed her to be able to start and stay on Suboxone. She had chosen to live outside of the area where she had been using and living on the street, and that made a huge difference to her. She had the support of the team, got involved in a day program, and she still comes to our Suboxone program here. She’s really involved. It all started with this epic day. When I hear her tell this story, she always says, “Kate abandoned me at the hospital!” And I did a little bit — it was the end of the day and I had to go. But, it really worked to her favor and she looks back on that day as this big change in her life where she was able to do what she had been wanting to do for so long.

Can you share something about your work that makes you most proud? Is there a particular story or incident that you found most uplifting?

I think the thing that makes me most proud is just the act of meeting people where they are and treating them with dignity. That can take many different forms. A lot of times that’s just listening to someone and truly hearing what they’re saying and experiencing. It’s validating what’s happening for them. It’s when they say, This is what I want to do, and this is my goal I think I can accomplish.” You actually meet them in that place and figure out how to do that with them.

The story I always think of — it’s not from this job, it’s from being a nurse in a hospital — but it’s what I always think about when I think about the impact we can have on people’s lives and the impact of nurses and nursing. When I worked in the hospital, I had a patient one night. It was only this one night shift, and it was a really, really busy night. So many things were going on. We would have five patients at a time. It was a high acuity floor and there was a lot happening. This patient had been in the hospital for a long time, and somehow she’d been transferred to our floor. I went in to check on her, it was nighttime, and she said to me, “My feet are really dirty, it’s really uncomfortable.” I got a warm wash basin of water for her with soap and a washcloth. I gave it to her and got her set up with it and I left, and that was that.

I continued on, I was her nurse for the rest of the night. I took care of whatever she needed and I gave her meds. I said bye to her in the morning. Several years later, I briefly worked in home care hospice. I was working on the home care side and I was covering a weekend shift, so I was in a territory that was not my typical geographic location. I went to this woman’s house and she said to me, “I know you. I remember you from the hospital. You helped me wash my feet one night and it was everything to me. It made me feel human. It made such a difference to me.” She got her journal and she read to me where she had written about this experience. I, of course, just wanted to help her and she said she needed to wash her feet, so I got her a basin of water and a washcloth. To me, it just shows that you never know what small act can have an impact on someone. I honestly did not remember her. I remembered that night, but I would not have recognized her when I came to the door. It was just incredible that she remembered me and remembered this experience.

So, I often think of that in these day-to-day interactions we have with people. Something small that you do for someone — that gives them dignity, that’s humanizing to them, that lets them take care of themselves in a way that they’re not otherwise able to — it can make a huge, huge difference. I was lucky to have learned how much of an impact this had had, because you usually don’t know, but you can make those impacts all over the place and I think that’s important to remember.

Can you share three things that the community and society can do to help you address the root of this problem? Can you give some examples?

I came up with two:

First, ending the stigma around substance use. People are still really embarrassed to disclose substance use because it’s still treated as a moral failing rather than as an illness. That is a huge barrier to people receiving care. People are scared to go to the hospital because of how they’ve been treated in the past. They’re frightened of not being helped when they’re in withdrawal and I have heard people say terrible things to folks who are substance users in the hospital, like, “You did this to yourself. You have to suffer.” People are frightened of those responses and, as a result, they don’t seek the care that they need. That stigma is huge. I think to start to talk about substance use, and treat it as an illness, makes a huge difference. There are some health systems in our area that are starting to do that — Substance use is just part of your health history, like your diabetes. We’re going to treat your opioid use disorder and it’s not made into a huge deal. I think we need to move towards that.

Second, supporting initiatives that have not been supported previously — such as overdose prevention sites, or safe injection facilities. The idea behind these places is that people will have an environment to safely use drugs that are not provided by the site but that they bring in themselves, so that they can be monitored for overdose. It will save people’s lives, but it also is a place where people can again receive services without stigma, and a lot of times, internationally, overdose prevention sites act as a hub for people who do want to get into treatment, who need housing, who need medical care, and people end up accessing much more services that they really need as a result of being a part of that program.

If you had the power to influence legislation, which three laws would you like to see introduced that might help you in your work?

I think the first thing, again, would be the overdose prevention sites. I would like to see legislation clear the way and the largest barrier to this is, obviously, federal regulation. There are local barriers as well. This has been an issue in Philadelphia where there’s been a lot of community push back. Philadelphians, their families, and their neighborhoods have been impacted by the epidemic and there’s a lot of trauma around it. There’s a long way for us to go to get everybody on board with overdose prevention sites, but I believe legislation would be helpful.

The second thing is changes from SAMHSA, in terms of their recommendations and regulations around medication assisted treatment, which have been brought about because of COVID-19. Previously, because of the Ryan Haight Act, a provider had to perform a physical exam of someone before they could prescribe a controlled substance to them, which included buprenorphine. Because of the pandemic and the limited availability of in person visits, those regulations were temporarily changed to allow people to initiate buprenorphine — so to get a first-time controlled substance prescription, without a physical exam — via telemedicine. That really increased people’s access to medication assisted treatment.

We have a very low barrier medication assisted treatment program at Pathways to Housing PA, which is a collaborative effort with our onsite medical clinic, operated by Project Home. We were already allowing people to do in-home inductions of buprenorphine, meaning they could start the medication on their own, not in the office. Now, people are not only able to do that, but are also able to get a prescription without physically coming into the office. They can just talk to a provider via telemedicine. That really increases access, so I would like to see that remain as an option rather than go away when COVID-19 is over.

The final thing that I would like to see is having automatic voter registration and for Election Day to be a holiday. I think the folks that we work with are often left out of legislation. They don’t have a strong voice, and one way to help people would be to bring more people in to vote and to make voting more accessible.

I know that this is not easy work. What keeps you going?

The work itself is not hard. I love being with the folks that I work with. I really enjoy what I do. Hard things happen and there are very hard days and sad days. When people die, when people relapse and they’re heartbroken over it, when they lose a relationship, when someone they know has died, when they’re not able to get the medical care that they need — those are all challenges that we work with. The people that we work with, I think, are what keep me going. I learn so much more from the patients that I work with than I think they probably learn from me. I really enjoy helping people through this process and we both learn a lot when there’s a problem that needs to be solved. That keeps me going. I just enjoy the relationships that I have with people.

Do you have hope that one day this leading cause of death can be defeated?

I do. I do have hope. I really do not see the crisis that we are in with opioid use disorder and with drug use, in general, in the United States, as a reflection on the individuals who are suffering. I really see it as a reflection of society and systems that we are living in. I do have hope that those things can change. There are many, many factors that have led to what’s happening right now. I think we can address the problem and improve the outcomes , but I don’t know about ever completely getting rid of substance use disorder. There are reasons that people use substances. But I do think that we can negate some of the negative impact that drug use is having on people’s lives. It will need to be multifaceted approach towards changing systems, changing legislation, and changing how people access healthcare. I don’t think there’s one single solution. I think we really have to take this multi-pronged approach. We need to keep looking at evidence-based practice and keep doing all the things that we already know to do to continue to make an impact.

How do you define “Leadership”? Can you explain what you mean or give an example?

I think of a leader as someone who walks alongside their colleagues, doing the same work that they do, but who has agreed to take on some additional responsibility for the outcomes and the organization of what’s happening. That’s really how I see my role. I’m the Director of Nursing at Pathways to Housing PA, but I’m also a nurse. I’m very proud of being a community health nurse and working in the way that I do. I see my role as helping everyone around me as we all do the work to organize ourselves, solve problems that arise, and improve the services that we are providing. I see that as my role as a leader.

What are your “5 things I wish someone told me when I first started” and why. Please share a story or example for each.

I mentioned how disillusioned I was when I first became a nurse. I had this idea of nursing practice as a holistic practice. Nursing has its own approach, and it is this kind of whole person approach. I was expecting to be able to implement this in the hospital, but I quickly learned that I was struggling just to keep people alive. To even begin to address the other aspects of their lives that were impacting them, including family, housing, past trauma, etc. — there was no time to think about any of those things. So, I think the first thing I wish someone had told me was just to prepare me for what a mess the whole system was because it was so shocking to me to see it in practice. I really was overwhelmed by it. I wish I had known that, and also understood that there is a way to work within that system. Many people are doing good work within that system, but it takes some practice and some perseverance to be able to do it.

Second, I wish I had understood that you don’t have to start in the hospital as a nurse. A lot of people will say, without being a hospital nurse first you cannot have any other job because you’re not going to know anything. While I did learn a lot in the hospital, it was also very traumatizing and I did not enjoy working there at all. So, I wish I had known that that was not necessary and I wish I could have known sooner that there is a place for everyone in nursing and within the medical system. There are so many things that you can do in nursing and it took me several years to find something that was the right fit for me. I’m glad that I persevered. A lot of people who become nurses stop being a nurse within the first year of practicing because it’s so difficult in the setting that they go into. I do not recall the percentage of people that drop out, but it’s surprisingly high. So, I wish I had known at the time, this doesn’t mean that you can’t be a nurse. There are other ways that you can fit into the system and make an impact.

Number three — Be ok with being wrong. I think this is something that has grown on me over time, just with being older and having more experience. I used to feel very uncomfortable with being wrong and really embarrassed when I was. I have realized that I’m wrong all the time. People are always proving me wrong — my patients, in particular. I may say to them, “I’m really worried about this. I think you need to go to the hospital,” and two weeks later they’re like, “Hey, check it out! That abscess? It’s fine. I handled it on my own. I took care of it!” That’s a simple example, but I do think it makes a difference in how you navigate your life. You don’t want to be haphazard and sloppy, but don’t be too concerned about being wrong, because sometimes you will be. Just gotta keep it moving!

Number four: When I first started as a nurse, I did not fully understand the impact of trauma and of structural racism in people’s lives. Working for over ten years with people experiencing homelessness, I have come to realize it impacts everything about people’s health, their lives, and the way they navigate the healthcare system. People have been treated very badly. The system is not working in their favor. There are historic wrongs that are present in their minds that they remember when they’re being asked to participate in a study or being asked to try a new medication or being told that they need insulin. That all comes to bear on those decisions, and I think when I was a new nurse, I did not fully appreciate them.

Number five — Trust your judgement. This is advice that I think is true across the board, but particularly for new nurses. I often talk to newer nurses about, for example, doing a physical assessment — If you hear something or you don’t hear something, or this is the blood pressure that you get, or you have a bad feeling about the way someone is presenting to you — that is your judgement. Even if someone else is hearing or assessing something different, you shouldn’t feel pressure to change what you’re experiencing. Your judgement is your judgement and that has an important role in the whole picture of what this person’s assessment is going to be. You should speak up when you think something is wrong or when you’re concerned about someone.

You are a person of enormous influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂

Right now my passion is this notion of harm reduction in healthcare. It’s a challenging thing for people, including for myself in some instances, and I have kind of grown into it I think. In healthcare, we have this idea that we know the best way to treat something. We think we know what is going to get the outcome that we want, and we want the patient to do that. A good example is when someone comes into the hospital with an infection and the doctor, or the team, decides that they need intravenous antibiotics. For our folks, that means staying in the hospital for six weeks and that’s very, very difficult if you’re not in a place where you’re receiving adequate withdrawal management. If you’re not receiving adequate treatment for your opioid use disorder, it’s hard to tolerate that and so people often leave the hospital against medical advice– before they are being discharged, they leave. There’s this notion that this is the best treatment, it’s IV antibiotics or it’s nothing — and if you’re leaving, you’re getting nothing, and that’s a shame because you’re making the wrong choice.

There actually is this kind of grey area, which I think is harm reduction in healthcare, which is to say — having an oral antibiotic is, perhaps, not the best choice. It may not create the best outcome. It may or may not work. But it might. For someone who’s not able to tolerate being in the hospital, I do not think it is practicing good medicine to provide them with nothing because they’re not agreeing to the one plan that you think is the best plan. This is challenging for people ethically. It’s a difficult grey area, but I would like to see a shift in providers thinking about other ways to meet people’s needs when they cannot stay in the hospital, or when they cannot tolerate taking a medication twice a day. What would help them? What would work to improve their quality of life and is going to meet them where they are? That is difficult for providers to do, but I think it could make a big impact on people’s lives.

If you’re willing to meet someone halfway like that, you are building a relationship with them. You’re helping that person literally to live longer, and they have more of a chance, then, to determine for themselves that they can take that next step. The next step might mean taking the medication twice a day, going into the hospital, or having the surgery that they’re very scared of having. It builds that relationship and trust in the medical system, rather than this “all or nothing” situation, in which the person has to completely buy into the plan that you think is the best plan, or they receive no healthcare. I would like to see us practice in that middle ground a little more — meeting people where they are.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

I do not have a favorite life lesson quote. But, I have a quote that I do not like — which inspires me. Over the years of working with people experiencing homelessness, and now, people with substance use disorder, I have heard from so many different people– from nurses, students, doctors, administrators– this idea of, “It must be so hard to work with people who don’t want to help themselves. You can’t help someone who doesn’t want to help themselves.” I find that so offensive. I believe that every single person wants to help themselves. It’s ridiculous to think someone doesn’t want to help themselves. Someone may not want to help themselves in the way that you would do it. Or, someone might be helping themselves in a way that is actually harmful to them in the end. But people have to find ways to deal with pain and trauma. For example, substance use can be helpful in providing relief for immediate pain, and it is effective in that way, but it has impacts on the rest of their life as well.

That does not mean, however, that the person does not want to help themselves. I think if you’re saying that about someone, you have not really listened to them. You have not met them where they are. You have not done the work of understanding what is happening for them. When people come to you — even someone who is wanting to harm themselves — they’re looking for a way to get relief. They’re trying to help themselves in the way that makes sense for them at the time.

Our role is to help people from that place where they are and help them figure out how they can take steps to help themselves. We help make them safer, help protect them, and help get them to where they want to be.

Is there a person in the world, or in the US whom you would love to have a private breakfast or lunch with, and why? He or she might just see this, especially if we tag them. 🙂

I just want to say, I like how the bar is being set lower with a breakfast or lunch instead of a dinner.

Of anyone in the world, I would like to meet with people who are doing harm reduction work in Portugal. They have decriminalized substance use and have a huge social safety net, which has taken the place of law enforcement around those issues. They have been really successful and I would love to know more about how that happened, and their processes.

In the United States, the person I would love to have breakfast or lunch with is a running hero of mine, Desiree Linden, who won the Boston Marathon in 2018, and who is a person with a lot of perseverance who I admire.

How can our readers follow you on social media?

They can check me out on Twitter at @katesotweetsy, although I do not have an active social media life.

This was very meaningful, thank you so much!

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