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Margot Kushel MD Profile picture
Margot Kushel MD
@MKushel
Director @ucsfcvp & @ucsfbhhi Professor Medicine @ucsf & Board member @housingca & @homeless_law Passionate about ending homelessness. Views my own.
Mar 25, 2022 • 16 tweets • 7 min read
Housing First works. We have tons of evidence to support it. The problem is--we don't have the housing. The soln: we need to preserve, protect, produce housing for the lowest income renters. Happy to talk to @BigadShaban @nbcbayarea about the evidence. 1/x Discussed our eval study w @mravenEM @DSTNHome @SCCgov @abode_services @ucsfbhhi which showed that even the "hardest to house" ppl could be housed FOR YEARS w/o preconditions 2/x

hsr.org/node/664701
Jul 14, 2021 • 9 tweets • 6 min read
A🧵about #COVID vaccines. The @ucsfbhhi has spent last several mos working w great partners to provide vax to folks in the Tenderloin--including those who are homeless/formerly homeless. After providing 2500+vax to folks who face many barriers to vaccines--some thoughts: 1/x Bright mural on wall, tree holding homes with inscription: E We talk alot about vax "hesitancy" but--we found, access>>>hesitancy. We had small, local sites (@GLIDEsf & Boeddeker Park)--with great outreach/ no appts needed. Helpful for those who couldn't get to mass vax sites. Reached 100s of folx, but not enough: So, what worked? 2/X Sunny day, blue topped tends on city street with ppl in them
Oct 19, 2020 • 12 tweets • 3 min read
This policy change is v problematic. Don't be fooled by talk of ⬆️mental health. The reason homelessness has ⬆️ is bc the fundamental drivers of homelessness: income inequality, lack of deeply affordable ("ELI") housing & racism-- have worsened. A 🧵 1/x
bit.ly/3dF5Sdn Housing First has a strong evidence base. Our recent study showed it successfully housed 86% of the "most difficult" to house chronically homeless ppl w high rates of substance use and mental health disabilities. hsr.org/node/664701 2/x
Sep 25, 2020 • 20 tweets • 8 min read
Our paper, RCT on PSH for the highest user of healthcare is out @HSR_HRET. PSH w/ intensive case management ends homelessness for 86% of the highest users of multiple services. A lot of subtlety here. A 🧵@mravenEM @ucsfcvp @ucsfbhhi @ucsf onlinelibrary.wiley.com/doi/full/10.11… 1/x Multi-year RCT comparing PSH (subsidized housing, mostly scattered site; ICM 1:15 master’s trained led team by @abode_services) vs usual care for chronically homeless ppl who were highest users of acute healthcare/jail in @sccgov 423 participants (199 intervent/224 control). 2x
Jul 7, 2020 • 26 tweets • 11 min read
Thrilled to be listening to @nhannahjones & Marla Newman, Chair BOD @NLIHC on #RacialEquityAndCOVID from lens of housing/homelessness! Image
May 15, 2020 • 12 tweets • 5 min read
Must read editorial in @nytimes on #homelessness that lays out the problem, where blame lays, & solution--"The fed govt could render homelessness rare, brief & nonrecurring. The cure for homelessness is housing." (YES!) A thread 1/x @BCAppelbaum

nytimes.com/2020/05/15/opi… 1. Problem is housing (not individual vulnerabilities) 2. Federal govt (& realistically, only Fed) could solve it 3. Instead, feds heavily subsidize wealthy homeowners, instead of low-income (mortgage interest tax deduction means homeowners live in deeply subsidized housing) 2/x
Mar 28, 2020 • 9 tweets • 4 min read
CA guidance on ⬇️ risk to homeless pops during #COVID19. Urgent need for private spaces (i.e. hotels) to ⬇️ risk. Can cohort those w infxn who don't require hospitalization (need tests!) in order to provide medical care. (Thread) 1/X

cdph.ca.gov/Programs/CID/D… Ideally, would have private room for all, but unlikely. So, a prioritization scheme. 1) need social distancing (& hygiene)/encampment in shelters & aggressive syndromic screening in shelters & encampments 2) prioritize ppl likely to have ⬆️risk complications for hotels 2/X
Jan 9, 2020 • 4 tweets • 2 min read
In RCT, Dr. Amy Finkelstein @JPAL_NA found no effect of Camden Coalition Hotspot program on acute care use. A few thoughts: 1) if we want impact, likely need to move upstream. Case management etc important--but doesn't change drivers of poor outcomes 1/

nejm.org/doi/full/10.10… Homelessness/housing instability/structural racism/trauma/etc. Not surprising that downstream programs (even outside standard healthcare) might not be able to solve deep seated problems 2) Yet another reminder to be very wary of pre-post non-controlled study designs. 2/
Dec 19, 2019 • 6 tweets • 4 min read
Role of racism in perpetuating homelessness in late life: new #HOPEHOME qual study led by @dereckpaul Black Americans 3-4x ⬆️ risk homelessness. Key take homes: 1) It's racism, not race (1/x) tandfonline.com/eprint/XYYVVPJ… 1. experiences of early life overt racism create risk 2. Structural racism throughout life course (i.e. criminal justice & employment discrimination, exposure to violence, premature death, and limited family wealth) ⬆️ & perpetuate risk 2/x
Dec 18, 2019 • 4 tweets • 1 min read
Watch this. & remember, In CA, there are 22 units of housing affordable & available for every 100 households who earn <30% of area median income nytimes.com/interactive/20… via @nytimes Remember that homelessness is result of 40 yrs policy failure w massive disinvestment in Federal support for affordable housing. Caused & compounded by ensuing structural racism. W rising income inequality, this is the reality for too many
Dec 11, 2019 • 5 tweets • 2 min read
Giving a talk in So Cal. Talk before me, govt official quote my work (even my direct quotes) w/o citing me. But cites a man whose work is complementary to mine—and cites my findings as his. Name checks him, has his name on slides. My work attributed to him. #womeninmedicine SMH Tx all. I mentioned it to speaker b4 talk (on way to podium). She said her staff had done her slides. But after my talk, she was extremely gracious, apologized & said she was going to speak to her staff. I thanked her
Dec 4, 2019 • 4 tweets • 2 min read
Great study comparing residents of public housing (PH) (subsidized, project based housing) who received vouchers to leave PH & enter private market (w subsidies) (1/2 restricted to low poverty neighborhoods) by @cepollack in @jama 1/X ja.ma/2RnPQvg Vouchers (c/w PHA) associated w ⬇️ hospitalizations/health $ in kids but not adults. NOTE: everyone in study had SUBSIDIZED housing--so study looking at difference bw PH (concentrated poverty) w vouchers (less concentrated poverty)--NOT difference btw subsidy/no sub 2/x
Oct 7, 2019 • 6 tweets • 2 min read
Unsheltered homeless (c/w sheltered) ppl ⬆️likely to report mental health/substance use as cause of housing loss; ⬆️ length homelessness ⬆️ police contacts & ED visits. Important new report by @CAPolicyLab bit.ly/Unsheltered showing services NOT reaching highest risk 1/ Lots of caveats (use VI-SPADT data) but key take home: services are NOT reaching those at highest risk. Authors appropriately do NOT make causal claims--this doesn't mean shelters lead to ⬇️ MH/SUD--but point out that shelters missing those at highest risk. 2/
Aug 30, 2019 • 12 tweets • 3 min read
Important CEA of RCT of Housing First w Intensive Case Management (HF-ICM) vs tx as usual (TAU) 4 ppl w homelessness + mod mental health/substance use prob in Canada. (high qual CHEZ SOI study-DAYS HOUSED as measure effectiveness) bit.ly/2Zz0Lmw @jamaopennetwork 1/10 Take homes: 1. HF-ICM is effective at housing ppl w MH/SUD. 2. HF offsets about ½ the cost of providing intervention through ⬇️ shelter, supported housing, SUD tx, & ambulatory visits (NOTE—some of cost offsets were from ⬇️ cost of subsidized housing w staff present) 2/10
May 10, 2019 • 15 tweets • 7 min read
From stop & frisk to mass Incarceration as a driver of health disparities. Can’t talk about health inequities w/o discussing criminal justice system (&racism) #SGIM19 1/x ImageImage US incarceration rates exceed 20 developed democracies. Incarceration rates not related to violent crimes. 1/3 black men will be incarcerated lifetime (racism, not race). Incarceration traumatizes individuals, families, communities ImageImage
May 10, 2019 • 16 tweets • 6 min read
Anti racism in action: name racism (it’s not race it’s racism) & interrogate mechanism. Racism creates opened & closed signs in our society. It is difficult to recognize a system of inequity that privileges us Dr @CamaraJones #SGIM19 recognize the 2 sides of the sign! ImageImageImage Racism exists even if we don’t see it. Racism is a SYSTEM of power to structure opportunity & assign value. Based on social interpretation of how one looks Image
May 10, 2019 • 7 tweets • 6 min read
So proud of the @UCSFPCRF fellows! So great to see your work at #SGIM19 Dr @TimAndersonMD presenting his work w @MikeSteinman cautioning against adjusting BP meds inpatient when uptitration in older adults assoc w harm (Rec: Inpt teams should communicate w outpt provider for close follow up ImageImageImage
May 9, 2019 • 4 tweets • 2 min read
Low barrier tx w buprenorphine: same day MAT for #homeless ppl. ~50% filled bupe rx &1/7 ongoing care @MInczeMD presents #SGIM19 plenary MAT saves lives. @SF_DPH @UCSF collaboration innovative program to meet ppl where they are ImageImageImage How to ⬆️ retention? (Hint: Housing would make a lot easier) but until we have housing, need to decrease mortality from OUD. Role for navigators?
May 5, 2019 • 25 tweets • 7 min read
TY @Gsainthelen & @kfrhoads I understand ppl’s skepticism & appreciate engagement. Will try explain what we are trying to do with the Initiative (which is, btw, not a study) (LONG Thread) (and please join us tomorrow 5/6 noon PDT #HomelessnessChat) 1/x We know that cause of homelessness is the lack of affordable housing, particularly for those making <30% area median income (AMI). Also: historical/structural racism, income inequality/lack of living wage/lack of pensions, ableism. This is what causes homelessness 2/x
May 3, 2019 • 6 tweets • 3 min read
Yes!⬇️⬇️⬇️ We all agree that the soln to homelessness is housing & PSH solves chronic homelessness. We know that there are many ?? about best way to design programs/systems; build political will; align health & housing for those w high needs. (Housing is the best medicine) 1/x We look forward to working w those w lived experience, those designing programs & policies to ID the key ?? & work collaboratively to answer them. At @UCSF @Benioff Homelessness & Housing Initiative--this isn't research for research's sake 2/x
Apr 25, 2019 • 4 tweets • 2 min read
"He was just not who I would have typically thought about as homeless..." Important paper re: screening for housing status in VA by @manikchhabra in @JournalGIM. VA is leader in screening for housing in health settings--in study HCP split on role (who should do it & why) 1/X But: 1) note how standard screening challenges their preconceived (& often inaccurate) view on who is homeless 2) changes clinical practice. Agree w all--and FWIW, fully believe (to borrow phrase) #thisisourlane. There is no medicine as powerful as housing. We have to ask! 2/X