Health care for the homeless: current practices and challenges

Health Care Services for the Homeless

An Analysis of Health Care for the Homeless, Milwaukee, Wisconsin

Today, one of the most significant problems facing underserved populations is an inability to obtain health care services in the marketplace. In fact, there is a strong relationship between homelessness and health; homeless people typically experience higher rates of physical illnesses than the general public, and in cases where access is severely limited, people will tend to use fewer health services and will typically experience worse health outcomes (Helvie & Kunstmann, 1999). Furthermore, the constraints to access of medically underserved and vulnerable populations is reflected in their higher mortality rates and increased rates of cancer, heart disease, strokes, and dental disease (Barrett, Epstein, Gaston & Johnson, 1998). Community health centers are the last resort for health care for many citizens who are so situated. One such national community health care organization that actively seeks to address the needs of the homeless and indigent is Health Care for the Homeless, which is discussed further below.

Review and Analysis

Background and history of the organization. Health Care for the Homeless (HCH) is a national organization with a number of branches across the country, including Denver, Albuquerque, St. Louis, Chicago, Phoenix, Boston, Venice (CA), Seattle, New York City, Baltimore, San Diego, Cleveland, Philadelphia, Los Angeles, Miami, Kansas City, Nashville, Washington, D.C., and Milwaukee, Wisconsin (Projects, 2005), where the author is a case manager. Today, Milwaukee is the center of a five-county metropolitan area with a population of approximately 628,088; however, the Milwaukee-Waukesha Primary Metropolitan Statistical Area (PMSA) has more than 1,432,149 by 2000 estimates (Milwaukee, 2005). On average, each of the Health Care for the Homeless (HCH) member projects across the country provides health care to 7,000 homeless individuals each year; collectively, these projects are the "doctor's offices" for 175,000 homeless people annually. On average, a homeless person's visit to an HCH clinic costs the project $99 (these visit do not costs the homeless person anything) (Projects, 2005). The services available at the Milwaukee branch of HCH include emergency and transitional housing, as well as a wide range of intensive support services to promote self-sufficiency; in addition, substance abuse, job preparation and employment assistance is also available.

Mission. Providing health care services that are specifically targeted at the needs of the homeless began in the 1970s; at that time, Brickner et al. (1985) introduced a model in which primary care was provided by physicians, nurses, and social workers in clinics and other sites where homeless people are found; secondary and tertiary services were then supplemented when needed. This model was implemented on a larger scale by the national Health Care for the Homeless Project (Helvie & Kunstmann, 1999).

Like other community health centers, the HCH is a nonprofit health care agency with a mission to promote health and primary prevention goals for specific populations in the Milwaukee PMSA; the targeted populations include the homeless, Medicaid recipients, migrant/seasonal farmworkers, individuals infected with HIV / AIDS, the underinsured, and the uninsured. Additional mission elements and their respective goals and steps to achieving them for HCH are outlined in Table 1 below.

Table 1. Key Homeless Change Concepts for the Elements of the Care Model (November 2002).

Self-Management

Decision Support

Clinical Information Systems

Delivery System Design

Organization of Health Care

Community

Recognize patient priorities are meeting basic needs of food and shelter.

Teach providers how to ask about housing status.

Use registry for identifying and tracking homeless patients.

Gather contact data from patient at each encounter.

Educate staff about causes of homelessness and barriers to care.

Increase public awareness and understanding of homelessness.

Set and document goals with patients collaboratively to support their independence.

Educate providers about barriers to care for homeless patients.

Enter contact data gathered at each encounter.

Use case managers to link patients to entitlements/benefits.

Furnish personal care items, snacks and socks.

Recruit volunteer specialists in podiatry, nutrition, ophthalmology, nephrology, etc.

Adapt guidelines and treatment protocols

Provide walk-in services and/or same day appointments.

Train staff in methods to engage patients into care.

Collaborate with homeless service providers, emergency dept. staff, criminal justice system and social service agencies.

Attempt to provide all services during a single visit.

Create interdisciplinary teams.

Establish procedures to waive fees for homeless people who are unable to pay for services

Recruit providers who embrace change and choose flexibility in the work environment.

Collaborate with faith-based agencies to provide services.

Cross train behavioral health and primary care providers.

Provide transportation: cab vouchers, bus tokens, van service.

Collaborate with homeless coalitions and advocacy groups.

Educate inter-disciplinary team members about individual roles.

Determine outreach staffing mix and services based on a needs assessment

Solicit donations to help meet care needs for test strips, footwear, glasses, healthy food, etc.

Conduct outreach where homeless people congregate.

Educate local businesses about homelessness.

Source: Health Disparities Collaboratives, 2005

The HCH's mission of providing health promotion and primary prevention has been expanded recently with the receipt of a Substance Abuse and Mental Health Services Administration (SAMHSA) 5-year federal grant that provides for additional health care services and screening if homeless people exhaust their eligibility for county benefits. This initiative was considered critical since the homeless are more at twice the risk of suffering from mental illness than the general population (Helvie & Kunstmann, 1999). Past estimates of the incidence of mental illnesses among homeless adults ranged from 16% to 91% depending on the methodology and definitions used; by any measure, though, substance abuse is common among the homeless, and Helvie and Kunstmann suggest that estimates by the National Health Care for the Homeless that 41% of their adult sample was alcoholic and 13% abused other drugs was a more accurate reflection of the incidence today. The individuals taking part in the SAMHSA grant program must agree to be periodically tracked over the course of their care to determine the success of the intervention, with a goal of successfully tracking 90% of the clientele at the end of the grant cycle.

Marketing. Health care for the homeless and indigent emerged as a major national issue in recent years (Carter, Green & Testani-Dufour, 1996). Unlike major corporations that employ entire marketing departments, though, the marketing efforts for HCH are more "hands-on" and involve a number of outreach programs designed to identify homeless individuals in the community and educate them as to what services and programs are available to help them in whatever capacity they desire. It is important in this regard for the health care practitioners at HCH to respect the dignity and desires of the homeless individuals with whom they come into contact and to not "push" them into a program even though it might appear to definitely be in their best interests.

According to Baumohl (1996), "All other things equal, counts that rely solely on shelter data or that are based on research conducted only at shelters will be lower than counts that search for homeless people in non-shelter locations" (p. 21). A number of researchers have attempted to identify the most effective method of "taking it to the streets" by searching outdoor locations as well as shelters. Still others search at soup kitchens, locations providing health care for the homeless, and sites that provide comparable services, and some, such as HCH, do both.

Some of these outreach programs include HCH case workers who drive around the community in agency vans looking for homeless people in places where they are known to congregate. When these homeless people are located, they are provided with information about what services HCH has to offer them, including a behavioral mental health clinic, medications monitoring, HIV drug and abuse screening and counseling, and a number of community support programs including a prenatal coordinator for at-risk pregnant homeless women.

Other marketing initiatives have been targeted at the homeless who have diabetes. At the request of clinicians who work with homeless individuals with diabetes, the HCH Network has developed a portable medical record or diabetes personal care card. Recognizing that homeless people may have trouble keeping up with the card or that it may be lost or stolen, HCH clinicians recommended that their homeless clients be provided with a way to carry the care card. In response, the national agency has made available small [4 1/2" x 5"] nylon wallets with two zippered pockets and a clear plastic sleeve. The wallet features a nylon cord to allow the card to be safely and discretely worn around the neck and under the person's shirt; the wallet with the visible personal care card stating, "I Have Diabetes," also provides a means of identifying the individual as having diabetes in an emergency (Health Disparities Collaboratives, 2005).

Management. According to St. Martin (1996), the provision of quality care is a guarantee for cost-effective, accessible care as a management approach in community health centers. For example, this author cites a study completed by Starfield et al. (1994) that concluded that there is a "generally higher quality of care for patients in medium-cost community health centers" than for those individuals whose health care is covered by Medicaid funds (p. 1903). The management goal for HCH is to improve the effectiveness of health care delivery to the homeless and indigent of Milwaukee in close partnership with the community. In this regard, the management of the HCH community health center requires careful and timely coordination between the community health care specialists, including family practice physicians and advanced practice nurses, who provide accessible primary care preventive health services.

There are also management issues related to how the Milwaukee agency is administered according to the policies and procedures promulgated by the national organization. For example, in order to provide more one-on-one contact with clinicians who have expertise in homelessness, the HCH Network also identifies clinicians from each of the five Clusters to work with the health center team in Milwaukee. This Network representative serves on the national organization's Cluster's Steering Committee; in this capacity, the primary responsibility of the Network representative is to share specific expertise and knowledge about providing primary health care to homeless people. This ongoing initiative is intended to help ensure that the unique needs of homeless people are addressed by the HCH Collaborative (Health Disparities Collaboratives, 2005).

There are also management issues related to the allocation of resources to target specific population groups in the Milwaukee PMSA. For example, Baumohl (1996) reports that children who are forced to live in shelters may experience poor health as a result of poor nutrition, communicable diseases that spread in congregate living environments, inadequate sanitary facilities, and to noise and light that disrupt sleep. "Shelters in many cities require families to leave during the day," he says, "making it difficult for young children to nap or for sick children to recuperate. Homeless children who live in cars, abandoned buildings, or in the open may suffer from exposure to the elements and are even less likely than shelter children to have adequate nutrition, sanitary facilities, and places to sleep" (p. 119). In many areas of the country, health care for such homeless children is provided by special programs operated by Health Care for the Homeless; however, in other parts of the country, access to timely care and a consistent health care provider may be difficult or impossible (Baumohl, 1996).

Money. Because resources are by definition scarce, it is critical that HCH remain a careful manager of the funds that come into its care. In this regard, the following tables provide financial statement data from 2004 for HCH. As can be seen in Table 2 below, at first glance, it would seem that HCH enjoyed a solid financial basis at the end of last year:

Table 2. Revenue and net worth for Health Care for the Homeless, Milwaukee, WI, 2004.

Revenue and Net Worth

Amount

Contributions

Other revenue

Total revenue

Beginning year net worth

Net worth changes

Year end net worth

Source: Wisconsin Department of Regulation & Licensing, 2005.

As can be seen from the "bottom-line" in Table 3, though, HCH incurred a $292,362 deficit in 2004.