“He was my only child and my best friend,” Rice said.

Today Rice is the outreach coordinator for Fairfield-based Connecticut Against Gun Violence, work in which she believes her son shares. This summer has been a particularly difficult time to be working against gun violence in Connecticut. New Haven, Hartford and Bridgeport have experienced a recent spate of shootings and 11 people have been killed in New Haven to date, one shy of the number of homicides for all of last year.

Janet Rice talks with Colleen Shaddox about how the loss of her son Shane shaped her purpose in life.

“I asked myself, in his short time here, 20 years, did he serve his purpose, and I realize now I’m serving his purpose,” Rice says. “I’m speaking his story, working with at-risk youth, doing everything that I can for gun violence prevention. I’m serving his purpose.”

Connecticut has the sixth lowest rate of gun-related deaths in the nation in 2018, according to the most recent data from Centers for Disease Control and Prevention (CDC). The number of gun homicides have fallen since the state passed laws restricting gun ownership in 2013. There were 226 firearm deaths in the state in 2012, compared with 186 in 2018. Most of those gun deaths are suicides. Homicides are concentrated in a few urban centers. More than two-thirds of gun homicides in Connecticut happen in Bridgeport, New Haven and Hartford. As tragic as mass shootings are, low-income neighborhoods and communities of color bear the brunt of gun violence.

For Rice, the toll is never-ending. In early March, she participated in a vigil for a young man who died by gun violence, an all-too-frequent part of her work as an advocate. Several years after she lost her son, a nephew was also fatally shot in Hartford.

Gun violence marred Oliver’s life long before the fatal day in October 2012 when an argument with an acquaintance ended with his death. Luis Rodriguez, also 20 at the time of the shooting, was convicted of murder and sentenced to 40 years. In his short life, Oliver had seen friends and classmates shot and killed.

“The sad thing is … our kids having to walk past the crime scene tape to get from their school, getting off their school bus,” Rice says.

On the day he was shot, Oliver was on his way to collect money for a car he’d refurbished and sold, according to his mother. He’d been buying cars and flipping them for a profit.

Daniela Altimari/Courant Photo.

In December 2019, Janet Rice and State Treasurer Shawn T. Wooden discuss a plan to divest in gun stocks.

Oliver was a born entrepreneur. He was about 7 when he started selling bottled water on the street outside his father’s office. Oliver deduced that he’d do better if he moved to the corner and convinced his dad that it was safe to stray a few yards farther from the office. The new location did boost sales, as did his decision to add juice to his wares.

“He had a head for business,” Rice says. She chuckles and lights up, as she always does when she shares a happy memory of her son.

“He was my guy,” Rice says.

There are things you can do to take precautions and be proactive and plan for your own safety.

C-HIT’s Colleen Shaddox talks with Rajita Sinha, Foundations Fund Professor in the Department of Psychiatry at Yale University and the founding director of the Yale Stress Center, about how to take control and manage fear during the pandemic.

Coronavirus has swept through 150 of the state’s nursing homes and, as of April 29, 1,249 residents have died — representing about 55% of all COVID-19 deaths.  As of last Thursday, there were 4,814 cases in nursing facilities.

Dr. Kirsten Wilkins, an associate professor of psychiatry at the Yale School of Medicine, talks with C-HIT’s Colleen Shaddox about strategies you can use to help your elderly relatives – and yourself – cope during the pandemic.

People need connection and belonging. There are ways to achieve that online through volunteering and using new platforms to connect with friends. Low-tech sources of meaning like poetry and prayer are helpful too.

C-HIT’s Colleen Shaddox talks about ways to battle loneliness with Dr. Megan V. Smith, associate professor in the Departments of Psychiatry and the Yale Child Study Center at the Yale School of Medicine.

Parents are put in the difficult position of enforcing that isolation. Students are also experiencing many losses – Spring sports, prom, graduations, and field trips.

C-HIT’s Colleen Shaddox talks about how parents can support their teenaged children with Dr. Megan V. Smith, associate professor in the Departments of Psychiatry and the Yale Child Study Center at the Yale School of Medicine.

Creating reasonable expectations can keep parents from becoming overwhelmed in a high stress situation. Setting goals that are achievable – and carving out a bit of time for yourself — will make this extraordinary time more manageable.

C-HIT’s Colleen Shaddox discusses ways to find balance with Dr. Megan V. Smith, associate professor in the Departments of Psychiatry and the Yale Child Study Center at the Yale School of Medicine.

The death of Shirley Mae Burgess, Williams’ mother, at age 41 was a shock and a tragedy for her family. But it also is a story of how economic and social determinants of health shape lives.

Even though deaths from heart disease have been falling, it is still the No. 1 killer for both men and women, reports the Centers for Disease Control and Prevention (CDC). African Americans are at higher risk for heart disease and of dying from it, living an average of 3.4 fewer years than whites, a difference largely attributed to disparities in heart disease and stroke, according to the American Heart Association.

In this podcast, Colleen Shaddox interviews Gail Williams about how her mom’s death shaped her life.

Those with low incomes are also at higher risk of death from heart disease; studies show that as income increases, people’s risk of dying from heart disease falls 40% to 50%.

And, some of the leading causes of heart disease – smoking and hypertension –  have not lessened for people living below the federal poverty level, according to a study in JAMA Cardiology.

But statistics don’t begin to tell the story.

Her mother’s death changed Williams’ own life profoundly. At 15, she became the caregiver for her younger brothers. She stopped attending school after she became their surrogate mother. And the loss of her mother was not the only one she had to face. Three of Williams’ brothers have predeceased her – including a brother who died at age 38 of a heart attack. She has struggled with drug addiction, though she is clean now. After quitting drugs, Williams earned a high school diploma and a college degree. She studied human services and is active in a number of organizations, including Witnesses to Hunger.

Williams found it difficult to talk about her mother, but she was committed to being open about the painful experiences. “I want to make sure that me and my kids always had an understanding, was able to talk to one another. No matter what. I just want it to be different from what I went through,” she said.

A PCMH is a medical practice that provides comprehensive and coordinated care. That can mean helping a child get an appointment with a behavioral health clinician; making sure a patient’s apartment is free of asthma triggers; and many other services hard to get in time-crunched primary care offices. Medical homes must also provide a high level of accessibility through measures like extended hours, electronic or telephone access or rapid appointment scheduling.

The state instituted HUSKY PCMHs in 2012 with an eye toward improving care for patients with chronic conditions, according to Kate McEvoy, director of the Division of Health Services at DSS. Many were “people who were frequently using the emergency room when there may have been reasonable alternatives,” she said.

In this podcast with C-HIT’s Colleen Shaddox, Francesca Brown discusses how the person-centered medical home provides her family with individual, holistic health care.

PCMH practices outperformed other HUSKY clinicians in five of seven adult performance measures and all 10 pediatric measures that the state tracked in 2017, the last year for which data are available. That year 368,838 HUSKY members were served by PCMHs, with 191,606 being under the age of 21. About two-thirds of the clinicians providing primary care to HUSKY members practice under the PCMH model.

Pediatric PCMH patients have 3.37 percent fewer ER visits and adults have 6.25 percent fewer visits, compared with the whole HUSKY population, according to a DSS report. PCMH patients got recommended care at higher rates, including diabetic eye exams and medication management for people with asthma.

“It’s phenomenal. No innovation ever starts with poor people,” said Ellen Andrews, executive director of the Connecticut Health Policy Project. Coordinated care is especially beneficial for people in poverty, she said.

The state is spending less on HUSKY members seen in PCMHs, with an average monthly cost of $733.73, compared with $770.86 for HUSKY as a whole.

In some PCMH practices, staff wear buttons that say “Come see us first.” Every PCMH practice has employees who contact patients regularly to get them in for scheduled checkups, vaccinations and other preventive services. So, while PCMH patients are receiving less emergency care, they are also receiving more primary care, according to Dr. Lawrence Magras, chief medical officer of the Community Health Network of Connecticut (CHNCT), a Wallingford-based nonprofit that provides administration for HUSKY. He noted that HUSKY PCMHs have the highest rate of adolescents getting well-care visits of any Medicaid program in the nation, 67.6 percent. Scheduling the visits “is a challenge, because you can’t get teenagers to see a doctor,” he said.

Colleen Shaddox Photo.

Francesca Brown and son, Matthew Brochu, receive their primary care at United Community and Family Services, Norwich, a person-centered medical home.

The state offers PCMHs higher reimbursement than conventional Medicaid providers receive, as well as support that includes access to community health workers who help patients connect to social services. CHNCT also provides data that shows practices how they are performing.

Data can reveal ways to do better. Clinicians at United Community and Family Services (UCFS) in Norwich saw that their patients were not getting recommended colonoscopies. They simply could not get to the specialist who performed the procedures because the doctor’s office was not on a bus line. Dr. Ramindra Walia, the chief medical officer, hired a gastroenterologist to do screenings at UCFS, which is accessible by bus. Colonoscopy rates improved.

Walia is a strong proponent of the PCMH. “This is what I was living for. This is the community change I wanted to see,” he said. Traditionally medicine revolved around doctors, but he believes this model revolves around patients. He also enjoys the team practice model, where multiple clinicians are available to answer patient questions.

The state is piloting PCMH+, a variation of the model that offers higher reimbursements and requires more care coordination. The program calls for medical practices to get a percentage of savings that they realize through managing the care patients get. Some advocates who cheer PCMH are critical of PCMH+. An August report by the Connecticut Health Policy Project raised concerns that the model has poor preliminary results and could discourage practices from accepting patients whose health might not improve quickly, particularly members with disabilities.

Sheldon V. Toubman, staff attorney for New Haven Legal Assistance Association, objects to the shared savings feature. “As soon as the doctor has a financial stake in not sending you out to the specialist or not prescribing the most effective drug, they now are financially invested,” he said. Toubman is particularly concerned about large organizations that play a growing role in primary care. “As practices consolidate you can see how bringing in more revenue through shared savings can be more bureaucratized.”

McEvoy said that there are safeguards in place to prevent the problems advocates are raising. She cited a low opt-out and patient grievance rate for PCMH+. “We look at all those indicators on a rolling basis and we have seen absolutely no reason for concern with PCMH+,” she said.

Just over 364,000 people receive SNAP benefits in the state, a number that has decreased about 4.7% in the past year.

“I try to stay on top of everything that’s going on,” said Perez, a member of  Witness To Hunger, which organizes SNAP users to speak about food policy and poverty. Perez lives on just over $700 in disability assistance a month, plus $192 in SNAP.

Though her SNAP benefits are safe for now, proposed federal rule changes could push other Connecticut users off SNAP. The federal government is proposing to limit access for unemployed residents and for people close to the current federal poverty level.

C-HIT’s Colleen Shaddox spends time at the grocery store with Wanda Perez, a SNAP recipient who shops for food bargains.

Unemployed Able-Bodied Adults Without Dependents (ABAWDs) may only receive three months of benefits over a three-year period, but today in most of Connecticut they can receive waivers to extend SNAP longer based on unemployment rates. Under a proposed federal rule change, most of those waivers would end. Currently residents in 108 of Connecticut’s 169 towns qualify for the waiver.

“People are stuck, and it sometimes takes a very long time for people to get their feet back on the ground, and while they are doing that, they don’t need to be punished by not having enough food to eat,” said. Bernard J. Beaudreau, CEO of Connecticut Food Bank. He cited low-wage jobs, a gig economy and the difficulty older workers face in getting retrained for available jobs.

Gov. Ned Lamont, in a letter to the U.S. Department of Agriculture (USDA), said, “These waivers allow states to protect individuals in areas where finding a job can be difficult, by continuing to provide basic food support while they look for employment.” Lamont urged the USDA to increase funding for job training within SNAP. According to the governor, 70% of SNAP recipients who participate in training through the program find employment.

About a quarter of the people receiving SNAP have a disability that limits their ability to work, according to the Center for Budget and Policy Priorities, but not all of them meet the federal standard for disability – something that is getting harder to do.

Colleen Shaddox Photo.

Wanda Perez is a SNAP recipient who advocates for others in the program.

John Spilka, an attorney with Connecticut Legal Services, helps people qualify for federal disability programs, a process that he said can take years and offers poor prospects of success. “If you look back 20 years ago, we were probably winning 80 to 90% of our cases,” he said. “Today it’s much less.”

While applicants with resources may be able to visit specialists, who can document a medical case, Spilka represents underserved people. “My clients can’t pay for reports,” he said.

A second proposed federal rule change would also affect SNAP eligibility. The federal Office of Management and Budget proposed last month to change the way it calculates the federal poverty level that would effectively lower it and disqualify more people for benefits that are tied to the measure, including SNAP, Head Start and school lunches.

“You’re making a choice that is going to weaken all our basic assistance programs,” said Sherry Suber, SNAP program manager at End Hunger CT.

Suber and Beaudreau both said that the nonprofit food assistance system is already too small to meet that need. “Our resources haven’t grown,” said Beaudreau. “We’ve had very flat revenues in terms of donor support.”

Food insecurity is particularly acute in the summer, when children do not have access to school breakfast and lunch. The average child will miss 100 school meals over the summer break, said Beaudreau. Food programs around the state try to fill the gap, but access can be difficult in some areas, he said.

For Perez, summer is actually a better time for her food budget. She gets tomatoes and vegetables from her father’s garden. On a low-fat diet, she often looks for specials on fruits and yogurt. She walks past the fresh fish counter because “it’s too expensive.”

At 52, she’s already had a stroke. Her mother died of heart disease at 54, and Perez is working hard on eating well. “I want to be around to see my grandchildren become adults,” she said.

She expects to be talking with her members of Congress about the proposed federal changes soon. “Everybody got a voice,” she said.

“A cigarette is a friend,” said Williams, who lives with schizophrenia and chronic obstructive pulmonary disease.

People with mental illness account for 44% of the cigarette purchases in the United States, and they are less likely to quit than other smokers. High smoking rates among people with mental illness contribute to poorer physical health and shorter lifespans, generally 13 to 30 years shorter than the population as a whole.

About 37% of men and 30% of women with mental illness smoke. The rate of smoking among whites with mental illness is 35%; blacks, 33.6%; and Hispanics, 27.2%, according to Mental Health America. While smoking rates are dropping in the U.S., a decade-long study that began in 2000 showed no consistent decrease for people with mental illness.

Help to quit smoking can be hard to find.

In this podcast, C-HIT’s Colleen Shaddox explores the difficulties people with mental illness face in finding programs to help them quit smoking.

“The quit rates are so low that physicians are kind of weary about getting in there and fighting the fight,” said Dr. Paul Sachs, director of Stamford Health’s Division of Pulmonary Medicine.  Quit rates are low for all smokers, he added, but even lower for people with mental illness. Among the general population, less than 10% of smokers will succeed in quitting for six months in any given attempt.

“We need physicians to make it a priority,” Sachs said. He noted that office visits in a typical practice may be too short to have a meaningful discussion about tobacco. He suggests that doctors either designate a nurse practitioner or physician assistant as the smoking cessation specialist in the practice or refer patients out to someone who can support them in quitting.

Sachs heads the health system’s smoking cessation program. The program is accessible in the psychiatric ward but he found few takers. “If you talk to 20 people about it and one of them stops, it’s still worth it,” Sachs said.

Jean-Marie Monroe-Lynch developed a smoking cessation program for people in Wheeler Clinic’s Adult Services Department, which serves the most seriously ill among the agency’s clients. Lynch, who directs the department, said 70% of the clients in it smoke. With support, including group counseling, nicotine gum and referrals for sessions of acupuncture and exercise, 15% of those who signed up managed to quit for a week—a high enough success rate that Lynch wants to expand it. Even for those who did not remain smoke-free, there was a benefit, as smokers typically go through multiple attempts before finally quitting. “Some people didn’t successfully quit, but it gave them that thought process,” she said.

Lynch sees potential for cessation programs embedded in mental health organizations, where people can manage the depression and anxiety that led them to smoke in the first place. “The reason that most people start smoking with mental illness is that it masks their symptoms,” she said.

Colleen Shaddox Photo.

Katelyn Trauger, a social worker at Fellowship Place, holds a jar that she says represents the amount of tar a smoker’s lungs accumulate in a year.

Connecticut used to fund smoking cessation programs specifically for people with mental illness, using money from a multi-state lawsuit against cigarette companies. Now that money goes directly into the General Fund. “There has been no new funding for tobacco control outside of Medicaid since 2015,” said Bryte Johnson, government relations director in Connecticut for the American Cancer Society. The Centers for Disease Control and Prevention recommends that the state spend $32 million annually on tobacco control, but Connecticut has only spent a total of $29 million cumulatively since 2003, he said.

“It’s really unfortunate,” said John O’Rourke, director of CommuniCare, a mental health service program that serves greater New Haven. O’Rourke ran smoking cessation programs for people with mental illness, until the state funding ceased. Having programs that can address the interplay of mental illness and smoking is helpful, he said. “Quitting actually benefits their recovery,” he said. Abstaining from cigarettes can boost mood and give people a sense of accomplishment, according to O’Rourke.

Katelyn Trauger, a social worker at Fellowship Place, has charts to show clients, most of whom are low-income people with mental illness, how much money they will save from quitting. She also keeps a jar of brown goop in her office that represents the amount of tar a smoker’s lungs accumulate in a year of smoking a pack a day.

“It’s really, really, really difficult. A lot of people will use smoking as their last vice,” she said. Fellowship Place used to have a formal smoking cessation group, but Trauger ended that in favor of drop-in counseling, recognizing that keeping appointments can be difficult for the people she serves.

Cessation services for people with mental illness are rare enough in Connecticut that Trauger, who works in New Haven, gets calls from places like Wethersfield and Portland.

Williams is down to two cigarettes a day. “I can breathe now without wheezing,” she said. But she quickly added, “I have to stop.” With street drugs behind her, Williams is active in her church and community. She has a job. She has finally met her grandchildren. “That was miraculous!” she said. Williams wants to stick around for more experiences like that.

“I don’t want to die. I put the crack away,” she said. “I want to put the cigarettes away. I got to get right with myself. I don’t want to die just for a cigarette.”