ç Instead, he wanted to be a diplomat and join the Foreign Service.
However, the federal government canceled the foreign service exam just at the time he would have qualified to take it. Haile, who holds a law degree and master’s degrees in public policy and health economics, said his graduate school mentor showed him the connections between economics, program development, and service delivery. It fascinated Haile and got him hooked.
The mission of Neighborhood Health, a local nonprofit organization and the largest federally qualified health center (FQHC) in Nashville, is, “improving the health of our community by eliminating barriers to care and serving as a healthcare home without regard to the ability to pay.” It’s the perfect cross section of all of those connections he gravitated toward in school.
After living two years in South Africa where he worked in an HIV clinic, he returned to Washington, D.C., where he was working for the District of Columbia’s Medicaid program. He then became a consultant for about eight different Medicaid programs, and when the opportunity arose to return to his native state of Tennessee and be closer to his five nieces, he took it.
“I’ve always been really interested in how to connect budget, politics, program rules and legal structures with service delivery,” Haile said when asked why he moved from working for the state to taking over a healthcare nonprofit. “It was just a natural thing to move pretty seamlessly from state government, which is a wonderful experience, to something like Neighborhood Health, which is by far the best job I’ve ever had.”
How would you describe Neighborhood Health and its primary role in the Nashville health care system?
We are the most interesting medical and dental practice in the area and probably in the state. We have two clinics that focus on people experiencing homelessness, two clinics that are primarily focused on individuals who are immigrants and refugees, two clinics that serve public housing communities, and two clinics that serve rural areas. And we have five or six other clinics that serve all of the above.
We are a really diverse medical practice. Three quarters of our patients are persons of color, and in fact, Neighborhood Health serves more African Americans than any primary care safety net provider in the region. We serve twice as many Hispanic patients as both other national health centers combined.
So, it’s a wonderful place to work. It’s a very interesting place to work and by being the largest safety net provider of primary care in the region, what we do makes a difference.
Where are the locations of the clinics serving people experiencing homelessness?
We have the Downtown clinic, which people are going to recognize because it is right next to Room In The Inn and very close to the Nashville Rescue Mission. And we had a clinic at the Mission. That clinic was mothballed because we turned it into a COVID quarantine facility in March of 2020, back when we thought that we would need about seven beds for COVID quarantine. Those were different times, and we know a lot more now than we did then.
We sort of replaced that mothball clinic with our street medicine and mobile unit that’s doing rounds in encampments about five days a week right now. So, those are the clinics that are almost exclusively focused on homeless folks.
I want to be clear though, at every single one of our 13 locations. We serve anybody, and that includes individuals experiencing homelessness. When I look at the data for 2023, we absolutely served individuals experiencing homelessness at every single location.
Neighborhood Health is a strong partner in addressing homelessness in Nashville. What would you say are your most successful services that focus on addressing homelessness?
When I got here I kept thinking that what we do in the Downtown clinic, in terms of regular ongoing chronic care, was going to be the most impactful thing, and trust me, it makes an enormous difference! But the dental program was something that really struck me, and that I’ve come to understand is really life changing. If your front teeth aren’t OK or if they’re lacking entirely, it’s really hard to get a job in Nashville, even in this labor market. By restoring function and doing some dental stuff, it really improves someone’s employment prospects. So, I think the dental program is really important.
The second problem that we don’t talk about a lot, but really merits more attention is what we do on the substance abuse side. We have an intensive outpatient program for men with co-occurring mental health and substance use issues. We have a really strong partnership with Welcome Home Ministries where they provide the housing supports, and we provide the clinical services through [our] intensive outpatient program. It’s really been transformative. In fact, one of the patients who was treated in that program later went on to serve nine years on our board. He just stepped off the board last year after successfully completing that program, obtaining housing, and maintaining his recovery for all of that time.
During the COVID pandemic, Neighborhood Health partnered closely with Metro to coordinate vaccinations and other health services for the homeless population. What have we, as a community, learned from that time?
I think one of the things that was interesting about the pandemic is it did not allow for process. We couldn’t get in a room and have consultations. We couldn’t have open-ended discussions where people use a whiteboard and think things through. We had to get really creative about how to figure [things out]. What that forced us to do was do our homework before we got on Zoom, and be very prepared. We had to be able to explain it in ways that would make sense, even though we didn’t have a lot of materials to share back and forth.
[As an example,] it took about two or three weeks to come up with a plan, where we wanted to make sure that everybody experiencing homelessness in Nashville could have access to a COVID vaccination by Memorial Day 2021. We were able to do that.
Has that impact lasted and is continuing?
There are two things that we’ve got to pay attention to. One of which is people are tired, and that’s not insignificant because when we were starting to [address] COVID, we were coming out of a tornado response. We jumped into ‘what are we going to do about this pandemic?’ We pivoted at the end of the summer of 2020 to a COVID-testing response. We moved into a vaccination response. Then we went into, well, if you do get sick after you’re vaccinated, there’s this new antiviral called Paxlovid.
There was always something new. Over time, that has taken a toll [on people]. Understandably, there are people who are burnt out and have left this sector. That’s just a reality for all of us and that makes it a little bit more difficult to keep this pace, this momentum, going because some of those partners aren’t there anymore.
The second thing that’s different is, when you’re in startup mode and when you’re working with a public health emergency then you throw all the rulebooks out. Well, some of those rules are important. The lack of infrastructure, the lack of systems and processes were just a reality because, again, we didn’t have a playbook.
But playbooks are there for a reason and so part of what we have to get back to is the boring parts of personnel and procurement policies and learning how to work within those personnel and procurement systems, so that we can keep this energy alive the best we can. That requires real leadership and frankly, really incredible ingenuity on the part of the people inside the government that really understand personnel and procurement.
My old boss, the welfare director in Washington, DC, used to tell me, she said: ‘Brian, it doesn’t matter if I know the difference between a postage stamp and a food stamp. If I can’t do personnel, if I can’t do procurement, I can’t do this job.’ And that’s exactly right. So really having government insiders that are smart about how they’re maneuvering those systems and that are really talented in how they help communities build capacity, I think that’s really where the magic happens.
Do you think Nashville is prepared for a new pandemic? Where are the strengths and weaknesses?
Nobody is prepared for a new pandemic. I want to say that first and then say, and Nashville is part of that group, too. But Nashville is hardly alone.
We’ve done a lot of patting ourselves on the back for how well we responded, and we should because we deserve those accolades. Nashville as a community, I think responded really, really well.
But are we ready for the next one? No.
Because what the next one involves is a tremendous amount of uncertainty, lack of clarity, lack of federal direction and guidance, real hostility from certain corners of the state legislature. So, it’s going to be even more difficult to do that going forward. There’s probably less authority that the Mayor and the city have to respond [to a future pandemic]. There’s probably less infrastructure in place with the Health Department because of the turnover that’s happened there in the post-pandemic space. Everything that we learned, the people who learned it best, are probably not there any longer.
I am very concerned that if we had a widespread outbreak of Mpox in a daycare facility that spread to other daycare facilities. Where would we be? How would we react? What legal authorities are in place for the Public Health Department to take action? I’m pretty worried about how that plays out.
What are the barriers when addressing homelessness and health care, and what are the items that could be done now to remove some of those barriers?
One thing that I think merits attention is the time tax on the poor. Metro and really all of us do a really bad job serving the poor because the first thing anybody does, whether it’s a nonprofit, healthcare provider, or government agency, is we stick a bunch of forms in front of someone and say fill this out.
I really want to make sure that when someone applies for utility assistance through Metro Action Commission, or when they apply for WIC through the Metro Public Health Department, they’re not having to fill out form after form after form. That’s important because the people who need rent probably also need utility assistance. But right now, they have to go to different offices, fill out different forms, and those forms look a whole lot like the ones they filled out at the six different places that their church sent them to before they got to those offices.
One of the really boring things I’m excited about is [to explore] how we streamline that process. We’re in conversations with different homeless service providers, shelter providers, to [figure out] if they do an intake, how do we import data from them so that we really minimize what a patient has to fill out when they come to see us and vice versa.
The second thing that we really need to think about is if we’re helping people who by and large just need to get back up on their feet but they’re already working. Let’s figure out how we do that while reducing their time tax so they can spend their time making money and improving their lives.
Conversely, when we’re working with people who are disabled, we’ve got to acknowledge who takes the biggest time tax on the poor [which is the] Social Security Administration. On average, it’s about 27 months to a disability determination. During that time, those individuals don’t have any access to income because they’re disabled, they can’t work. But they have to wait all that time to get that disability determination from Social Security.
What Metro can do is exactly what Oakland, California, and Washington, DC, and a number of other large cities have done, which is put together an interim disability program that helps people who have applied for SSI. It gives them a little bit of money each month while they’re waiting for that SSI check to come in. And when the SSI check comes in, you know what happens? The city gets paid back for all the benefits that it paid out. But while we’re providing that interim assistance, that’s money the person can use to get a room. And if we just had that program in place that would probably be the single most helpful thing that I can think of that would help people, especially people who are disabled, access housing that they can’t today.