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- Health Care Serv;ees [or Homeless People INTRODUCTION To the extent that homeless people have been able to obtain needed health care services, they have relied on emergency rooms, clinics, hospitals, and other facilities that serve the poor. Indigent people (with or without a home) experience many obstacles in obtaining health care. For homeless people there are additional barriers. Recognition of the special health care needs of homeless people has encouraged the devel- opment of special services for them. In observing and describing these health care and health care-related services, one must be mindful of the heterogeneous nature of the homeless population, as well as the structure of the communities in which such services have developed. Regardless of differences among homeless people or regional variations in services, however, homeless people are more susceptible to certain diseases, have greater difficulty getting health care, and are harder to treat than other people, all because they lack a home. Similarly, attempts to provide health and mental health care services, regardless of variations in such areas as history, funding levels, and nature of support, also have certain common elements. They arose in response to a crisis rather than developing as part of a well thought out plan. They generally brought services to homeless people rather than waiting for them to come in; increasingly, they rely on public funding because the problem has grown beyond a level that the private sector can support. The purpose of this chapter is to describe programs that seek to bring general health and mental health care services to homeless people. The information presented in this chapter is largely based on the 11 site visits 103

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104 HOMELESSNESS, HEALTH, AND HUMAN NEEDS made by members of the study committee and its staff. Although the sites are not representative of the entire universe of programs for the homeless, they were selected to include the broadest range of programs possible and to be geographically dispersed throughout the country. In studying health care and related services for homeless people, the committee sought to examine a broad range of services developed over a period of time, rather than to focus only on specialized services or services that have been developed recently. However, what the committee observed were discrete services and programs. At no time did the committee encounter anything that could be appropriately called a "system" of services. Before describing how these various programs bring general health care and mental health care to the homeless, we must address two major issues: (1) what makes serving the homeless, in contrast to the indigent in general, more difficult?; and (2) based upon the literature and the site visits, what elements enhance a program's ability to provide such services to this population? In Chapter 3, we discussed those aspects of treatment that are especially difficult to implement when the patient is homeless. However, one must also look at the people who are homeless. William Breakey (in press) has identified characteristics of homeless people that affect the provision of treatment and the planning of health care services: Daily Activities Some homeless people live under circumstances that pose particular problems for developing a treatment plan. For many, it may be difficult to keep a supply of medication while living on the street. For an alcoholic trying to stay sober, a homeless existence may present too many opportunities for drinking. Some former patients complain that neuroleptic medications, prescribed for a schizophrenic illness, may make them too drowsy and interfere with their alertness against the dangers on the streets. Multiplicity of Needs- In addition to physical and mental health problems and difficulties with such things as housing and income maintenance, homeless people often also suffer from drug or alcohol abuse. Any health care program for homeless adults should expect that 25 to 40 percent of patients will suffer from serious alcohol or drug abuse problems (Fischer and Breakey, 1986~. DisaffiliationAlthough many homeless people establish individual support networks outside a family structure, some homeless people typically lack those networks that enable most people to sustain themselves in society. Such isolation often causes (and sometimes is caused by) a limited capacity to establish supportive relationships with other people. Difficulties in establishing and maintaining relationships can militate against the development of cooperation with health care providers and may be an important factor in explaining what is often inaccurately described as a "lack of motivation." Distrust In addition to their distrust of authority, many homeless people are disenchanted with health and mental health care providers. Some have had bad experiences with medications, hospitals, doctors, and other human service professionals and are leery of further involvement.

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HEALTH CARE SERVICES FOR HOMELESS PEOPLE 105 Except for anecdotal information and obvious indicators of utilization, it is not possible to assess the effectiveness of health care delivery systems for homeless people. There are no adequate data from which such assessments can be made. However, in its review of various programs for health and mental health care services for homeless people, the committee found that four common elements enhanced a program's ability to provide services to this population: CommunicationThose people and agencies involved in the effort to address the health care problems of homeless people interact regularly and frequently. Coordination Even if only in a most rudimentary form, there is some way in which clients can be linked with a wide range of existing services (i.e., health and mental health care, housing, social services, entitlements, etc.) by providers, rather than being forced to seek services without assistance. Targeted ApproachPrograms are aggressive in seeking the homeless, rather than passive in waiting for them to appear. This may be reflected by locating a program in a skid row area. Other programs provide outreach and seek out homeless individuals on the streets. Internal and External ResourcesThese constitute the range of re- sources that a program requires to carry out its function adequately, no matter how limited that function might be. Internal resources include reasonable funding and paid employees, in addition to the utilization of volunteers and donated goods and facilities. External resources include both the network of essential services described above and the ability to access that network. The Health Care for the Homeless projects, funded jointly by the Robert Wood Johnson Foundation and the Pew Memorial Trust, are considered by many to have been the single most effective network of health care services developed for homeless people in the 1980s. They are also generally viewed as providing a major impetus for Title VI (health care) of the recently passed Stewart B. McKinney Homeless Assistance Act of 1987 (P.L. 100-771. The first nationwide program to address the health care problems of the homeless, the projects' creation serves as a benchmark. Therefore, this chapter is arranged from the perspective of that unique role. The following sections of this chapter describe: (1) programs in existence prior to the Johnson-Pew projects ;* (2) the Johnson- Pew program itself; and (3) other programs that came into existence at * The term Johnson-Pew is not generally used to describe these projects. It is used in this report because the more commonly used name of the project, Health Care for the Homeless projects, could just as easily describe many programs that are not funded by this particular grant.

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106 HOMELESSNESS, HEALTH, AND HUMAN NEEDS roughly the same time (1984-1987) as the Johnson-Pew projects. The description of the third group is further subdivided, based upon the targeted populations. The final section of this chapter discusses various programmatic, administrative, and clinical issues identified throughout the course of the committees observation of these service delivery models. PRE-JOHNSON-PEW MODELS Several program models were developed to provide health care services to homeless people before the mid-1980s. The conclusion that they are effective models of service delivery can be drawn from their reported experiences and the fact that the major features of such models appear repeatedly in later programs (especially the l9 Johnson-Pew projects). Shelter-Based Clinics Shelter-based clinics provide the types of services most frequently found throughout the country. Recognizing a need to bring services to where homeless people can be found, those involved with shelters or health care have developed on-site clinics at shelter locations. Rescue Missions The committee visited volunteer clinics located at rescue missions in Kansas City, Los Angeles, Nashville, and San Diego. These rescue missions are coordinated on the national level by the International Union of Gospel Missions, but there is an even greater strength of coordination locally. Having served the homeless for extended periods, they are known to the community and have substantial access to existing networks of, for example, health care services, housing, and social services. The clinics tend to be staffed by volunteer doctors and nurses and rely heavily on private donations, both of cash and pharmaceutical and medical supplies (although some have begun to accept limited financial support from local governments). However, because of the religious aspects of the organizations that operate these clinics, not every homeless person is willing to go to them. Nonsectarian Programs Nonsectarian programs, such as the clinic at the Pine Street Inn in Boston, operate similarly to the religious rescue missions. They have developed strong sources of financial support, frequently from among

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HEALTH CARE SE RVICES FOR HOMELESS PEOPLE 107 local businesses, charitable organizations, and foundations. In the absence of any national coordinating or controlling body, they tend to reflect the characteristics and needs of the city in which they are located. Both the rescue missions and the nonsectarian programs face certain common problems: limited hours (many shelters are closed during the day), dependence on volunteers, limited access to some of the less common medications, limited specialty and ancillary services (e.g., podiatry and dental care), lack of an ability to perform systematic screening, and difficulty in obtaining both liability insurance and medical malpractice insurance (especially critical when volunteers are retired physicians who do not have their own malpractice insurance). Both the rescue missions and the nonsectarian programs are, however, major sources of private, not-for-profit, and non-tax-supported health care for homeless people. The Public-Private Programs Public-private programs share some of the attributes of all volunteer clinics, but they have often resolved some of the problems cited above. One of the oldest examples is the St. Vincent's Hospital and Medical Center Single Room Occupancy (SRO) and Shelter Program in New York City.* The initial program developed from an intern's concerns over the large number of people who arrived by ambulance from one SRO hotel. Outreach programs were designed to provide health and social services on-site at SRO hotels and municipal shelters. With some variance according to the site at which services are provided, an interdisciplinary team of a physician, a nurse, and a social worker established on-site medical clinics. In recent years, partial funding for the program has been received from the New York City Human Resources Administration, that city's department of social services. In addition to the benefits of on-site programming, the clinics and the Department of Community Services at the hospital closely coordinate their efforts. Homeless people referred to the hospital for specialized services are often treated by the same individuals whom they saw at the on-site clinic, improving the continuity of care and increasing cooperation with the care-giver. Health Care Services in Day Programs Day programs, which are similar to the shelter-based clinics identified above, provide services where homeless people can be found, but they differ from shelter-based clinics in that the sites are independent of * For a more detailed description of the St. Vincent's program, see Brickner et al. (1985).

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108 HOMELESSNESS, HEALTH, AND HUMAN NEEDS residential programs. One good example is St. Francis House in Boston, which has been described by its staff as "a shopping mall of services to the homeless." Various mental health and vocational guidance services are provided to homeless people in a single building located in what was once known as the "combat zone"* of Boston. Included in these services is a health clinic for homeless people that is staffed by volunteers and paid employees. A similar program, also in Boston, is the Cardinal Medeiros Day Center operated by the Kit Clarke Senior House. Located in a church in downtown Boston, this is a day program exclusively for elderly homeless people. Among its services is a food van that stops where the elderly homeless are known to congregate. A registered nurse who is part of the van team performs basic health assessments and referrals for anyone willing to accept this service. A second nurse, stationed at the Medeiros Center, provides more extensive services. The two nurses alternate between the van and the center, so they are familiar with both programs and are readily identified by the homeless people themselves. While the nurse reported to the site visit team that there is little opportunity to perform other than the most basic visual assessment of a homeless person's health status from the van, she indicated that the true value of the program came from gaining the confidence of homeless people and then referring them to the Medeiros Center at a time when she could perform a more detailed assessment. The fact that they knew her enabled them to overcome any fear that might have prevented them from seeking health care. A third program of this type is So Others Might Eat, known as SOME, a day program in Washington, D.C., whose primary purpose is to provide breakfast and lunch to homeless people. Since 1982, SOME has been the site for a medical clinic operated by the Columbia Road Physician Group, a group practice composed of four physicians committed to serving homeless and indigent people and providing on-site social services and substance abuse counseling. It has also been the site for a dental clinic operated by the Georgetown University Dental School.t Free-Standing Clinics In 1979 a somewhat different model for the delivery of health care for homeless people was started in Washington, D.C.the Zacchaeus Clinic. * The term combat zone came into common usage in the 1960s to describe a section of downtown Boston known as the site of strip shows, adult bookstores, and so forth. Because of its reputation as being the more "open" part of that city, it became attractive to street people. It is now undergoing commercial redevelopment. ~ Both the St. Francis House and SOME, as well as the Pine Street Inn discussed earlier, have expanded in the past 2 years as the result of additional staff provided by the Johnson- Pew projects in Boston and Washington.

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HEALTH CARE SERV: ICES FOR HOMELESS PEOPLE 109 The clinic was funded entirely by donations from individuals, churches, community groups, and small grantors. It used a combination of paid staff and volunteers. It was established as a free-standing clinic in Washington's inner city as a response to the unmet needs of homeless people. People found out by word of mouth that they could receive health care with dignity and without waiting for long periods, as they often did in traditional outpatient departments and emergency rooms (Bargmann, 1985). Although many health clinics have been developed in response to the needs of homeless people, they often also treat the domiciled poor, especially those who live in the immediate neighborhood. Other clinics were originally developed to serve poor people in general and now, for various reasons, find themselves serving increasing numbers of homeless people. SPECIALIZED HEALTH CARE APPROACHES Various other programs address the special needs of homeless people or the problems of specific subpopulations among the homeless. Respite and Convalescent Care One of the most serious issues facing those who work with homeless people is that many standard forms of treatment assume that the patient has a home; when that is not true, treatment is extraordinarily difficult. Convalescent (or respites services allow a homeless person to recover from an illness or an injury that does not require (or no longer requires) care in a hospital but that is of such severity that the homeless person should not return to a regular shelter setting. One example of a private effort is Christ House in Washington, D.C. As a result of a bequest, the Church of the Savior acquired and renovated an abandoned apartment house and converted it into a 34-bed respite facility; it has a paid and volunteer staff, including medical and nursing supervision and care. The Columbia Road Physician Group provides medical support, and all four doctors involved in the project live, with their families, on the top floor of the building, so that medical attention is available around the clock. When more intensive care is needed, local hospitals are used. A similar program is the 40-bed respite unit at the Charles H. Gay Shelter Care Center for Men in New York City, which is a public-private effort. The shelter (including the respite unit) is funded by the New York City Human Resources Administration and is administered by the Vol- unteers of America, which is under contract with the city. The respite unit is adjacent to the on-site medical and nursing clinic administered by

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110 HOMELESSNESS, HEALTH, AND HUMAN NEEDS St. Vincent's Hospital (see above) and receives nursing support from the clinic. Referral for backup hospital services is either to St. Vincent's Hospital or to one of the hospitals of the New York City Health and Hospitals Corporation. Residential Placement Many homeless people with physical disabilities, mental disabilities, or both who cannot live independently require supportive living settings. One program that attempts to meet this need is the Veterans Adminis- tration (VA) community placement program, which secures supervised housing for mentally or physically disabled veterans who are facing discharge from a VA medical center and who would be at extreme risk of becoming homeless. Members of the committee visited four such placement sites in Lexington, Kentucky. Three were private homes in which the individual homeowner contracted with the VA to accept patients from the medical center (the largest program accepted up to eight men) for supervised residential living. The fourth program was a personal care home licensed by the Commonwealth of Kentucky. The personal care home received clients from the state agencies serving the mentally ill and the mentally retarded, as well as from the VA medical center. This facility is larger (over 15 beds) and was specifically designed to serve a population in greater need of medical and nursing care. Although the residences were supervised and certified by government agencies, the actual funding for the individual veterans comes from their own VA benefits. In each of the programs identified above, communication and coordi- nation were accomplished by individualized approaches developed over a period of time with systems that were more or less unique to each city. The programs were primarily targeted to the homeless; funding and other resources ranged from the purely charitable to the wholly publicly funded. However, a comprehensive, cohesive system of services is lacking. Even those programs that had strong ties with a hospital did not network with programs that serve, for example, the mentally ill or substance abusers. THE ,lOHNSON-PEW HEALTH CARE FOR THE HOMELESS PROJECTS The most significant event to occur in the area of health care for homeless people in recent years was the creation of the Health Care for the Homeless grants, funded jointly by the Robert Wood Johnson Foundation of Princeton, New Jersey, and the Pew Memorial Trust of Philadelphia. In many respects, the creation of this joint program reflected the growth of the homeless problem and the fact that agencies that had

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HEALTH CARE SERVICES FOR HOMELESS PEOPLE Ill historically been able to provide services to the homeless could no longer cope with their increasing numbers. The national Health Care for the Homeless program was developed to provide cities (applications were limited to the 50 largest cities in the United States) with an opportunity to make a significant impact on health care delivery to the homeless. On December 12, 1983, in ajoint news release, the two foundations announced what was, in effect, the first attempt to address this problem on other than a local level. Cosponsored by the U.S. Conference of Mayors, the program guidelines required that cities forge a coalition of disparate groups of health care professionals and institutions, volunteer organiza- tions, religious groups, public agencies, shelter providers, and members of the philanthropic community. This coalition was charged with devel- oping a program to meet the health care needs of the homeless, improving their access to other supportive services and entitlements, and developing a strategy for continuing the program services after the termination of foundation funding: As such coalitions strengthened and institutionalized their functions, it was hoped that they would become permanent structures for addressing the health and related needs of the homeless beyond the four year grant period. (Clark et al., 1985) Of the 50 cities eligible for the program, 45 submitted grant applications; of these, 18 were funded under the national program and 1 city was funded under a special arrangement. A total of $25 million was allocated by the foundations, and each city received up to $1.4 million for use during a 4-year period. One issue frequently raised as a result of the Johnson-Pew projects is whether it is necessary to develop separate health care systems for the domiciled and for the homeless. The answer to that question depends on the resources of an individual community and the willingness of existing health care systems to respond to the needs of homeless people. Even the most rigid system can, over a period of time, change to accommodate new programs; therefore, when it is necessary to develop parallel programs, it is frequently with the expectation that at some future time the newer program will be incorporated into existing programs. An especially good example of this is the incorporation of the Nashville Johnson-Pew project into the municipal health department. Structure of the Johnson-Pew Projects The 19 Johnson-Pew projects are distinctly different and highly idio- syncratic, and as such, they reflect the specific needs of the 19 cities in which they are located. The original request for proposal issued by the Johnson and Pew organizations required that all proposals be developed

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112 HOMELESSNESS, HEALTH, AND HUMAN NEEDS by a broad-based community coalition. Therefore, not one of the 19 programs was incorporated as a separate entity (although several are now in the process of seeking such incorporation). Each grantee needed to establish a system of governance and fiscal accountability, in effect, a fiduciary agent. The more common models provide for the funds to be authorized to an existing health care-related or social service-related agency (e.g., in New York City, the United Hospital Fund of New York; in Philadelphia, the Philadelphia Health Management Corporation) or to a charitable foundation (e.g., in San Francisco, the Episcopal Archdiocese of California; in San Antonio, the United Way). In two cities (Newark and Phoenix), the funds go directly to agencies of the municipal govern- ment. It is not yet possible to determine which funding methods are most effective. In some of the projects, services are provided by staff who are employees of the project, with a single set of policies and procedures. Some programs rely on contracts with existing providers of health care services, to provide either specialized services (e.g. dental care) or general health care services to a specific geographic area (e.g., the New York City project has contracts with three existing health care agencies that provide services in different boroughs of the city). Staff are employees of the contract agency and are subject to the policies and salary schedules of that agency. Sometimes a mixture of direct and contracted services is provided. Certain services such as case management are provided directly by salaried staff, while other services such as clinic operations- are provided by a contractor. How services actually get to homeless people is probably the most varied (and creative) aspect of the Johnson-Pew projects. The methods of service delivery include mobile vans outfitted as clinics, mobile teams going to existing programs that serve homeless people (particularly shelters and soup kitchens), and central clinics located in areas where homeless people can be found in substantial numbers. Common Elements of Health Care Programs for the Homeless Although the Johnson-Pew projects are just past the midpoint in their 4-year grants, much has already been learned from these projects. As with the earlier models, there is no statistical basis to determine a program's success.* In the course of its review and after many discussions with service providers as well as the homeless people who receive care, * However, the Social and Demographic Research Institute data derived from the client contact reports of the various projects do represent the first such diagnostic and utilization statistical data drawn from more than just a single local source; they also represent a potential base for future evaluations of program effectiveness.

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HEALTH CARE SERVICES FOR HOMELESS PEOPLE 113 the committee identified the common elements that follow as especially significant. Holistic Approach Rather than treating an isolated health problem without considering the person's social or environmental situation, these programs provide treatments that recognize the interaction between the illness and the state of being homeless. The nature and level of the individual's entitlement benefits, for example, whether they are sleeping in the streets or in a shelter, where they get food, and so on, are taken into consideration in developing a treatment approach. Outreach Health care is brought to areas where homeless people can be found. These targeted services can then serve as a conduit by which other services (including application and advocacy for entitlement benefits) are offered. Empathetic Staff Staff are aware of the attitudes that increase their effectiveness in working with the homeless population. In particular, staff recognize the exigencies of survival that impinge on the day-to-day activities of the homeless and the effects of those demands on the individuals health and health care. Multidisciplinary Approach Teams working with the homeless encompass a range of disciplines, including physicians, nurses, physician's assistants, nurse practitioners, and social workers. Given the range and severity of illnesses present among the homeless population, when volunteers are used (especially medical or nursing students), proper supervision is provided. Case Management and Coordination of Services One of the most critical elements in serving the homeless involves the coordination of patient treatment and the provision of access to other health care and social services with the aim of breaking the cycle of homelessness. The most frequent approach is to include social workers as part of the multidisciplinary team. This individual keeps in touch with service providers at other treatment sites to ensure that the homeless person follows through with the treatment plan.

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HEALTH CARE SERVI ECES FOR HOMELESS PEOPLE 125 committee toured several programs for homeless individual adult women. Site visits were conducted to the House of Ruth, a shelter for homeless women in Washington, D.C., and the Firehouse Annex, a drop-in center and transitional residence for homeless women in Chicago. While neither of these programs is specifically a health care program, both are clinic sites for their respective city's Johnson-Pew HCH projects. Another issue in evaluating services for homeless women is the high reported prevalence of mental illness among them. The committee toured a program for homeless emotionally disturbed women at the YWCA in San Diego, a program funded in part by the San Diego County Division of Mental Health Services. Families The committee visited programs for homeless families in several cities, in particular Pilgrim House in Kansas City and Project Hope in Boston. These two programs are not specifically health care programs; however, Pilgrim House receives on-site health care services from Kansas City's mobile homeless health care team, and Project Hope receives services from the Boston Johnson-Pew family team. Another program that the committee toured was the Emergency Lodge in St. Louis, a large shelter for homeless families operated by the Salvation Army. Among the services provided to the families are daily health screening sessions and health education programs conducted by a public health nurse and a weekly clinic conducted by a volunteer health screening team. This program is unique in that it also has a free day care center, which enables homeless mothers to search for jobs during the day. One program that specifically addresses the health care needs of homeless families is the Venice Family Clinic in Los Angeles. This is a free clinic that has been serving the Venice Beach/Santa Monica area for more than 17 years; its program has been augmented by the Los Angeles Johnson- Pew project to allow for services to homeless families. St. Anthony's Clinic in San Francisco, operated by the St. Anthony Foundation, serves both homeless families and homeless individual adult men; however, in response to fears expressed by homeless mothers about single men, the clinic has separate entrances and treatment suites for each group. Although these two programs certainly are excellent examples of what can be done, actual programs specifically serving homeless families do not exist any- where in the numbers needed, especially in light of reports that this is the fastest growing subpopulation among the homeless. Homeless Youths The three studies of homeless youths cited in Chapter 1 (Boston, New York, and Toronto) each reported on shelter populations. Despite the

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126 HOMELESSNESS, HEALTH, AND HUMAN NEEDS differences among the study populations, the similarities in the findings regarding the physical and mental health needs of this population are even more significant. All three studies reported that supportive services, rather than the provision of housing alone, are needed. Each also reported that both the number of attempts to run away and the length of time that the teenager has been away or in shelterks) are important. The greater the number of attempts to run away and the longer the adolescent is in an institutional setting, the more difficult it becomes to place that youth in a noninstitutional setting or, having made such a placement, for that youth to remain there. While the three studies disagreed on the form that noninstitutional services should take, they agreed that, given the problems of this population, specialized services for this group are necessary. The study by the Greater Boston Adolescent Emergency Network (1985) of Massachusetts emphasized the changing role of shelters in the network of youth services. In the 1960s and 70s a network of emergency shelters was developed across the country to house an increasing number of ''true runaways," young teens who had fled from a horrific home environment and had no place to sleep. From the phone booth on the corner or from a poster on a bus station wall, they were able to locate the nearest shelter and find a safe haven. Today, this still happens, but it is the exception, not the rule.... Due to the lack of other resources to accommodate and treat the chronic system youth, emergency shelters have become 30 to 45 day warehouses for adolescents with no place to go. Twenty percent (20%) of our sample were referred to shelter care not to manage a crisis, but specifically to shelter the youth while long-term care was being arranged. An additional 15 percent were referred from another temporary shelter. Members of the committee toured the Larkin Street Youth Center in San Francisco. This program, funded in part by federal, state, and local governments and in part by charitable donations, serves runaway and throwaway youths in the Tenderloin section of that city. It provides services, including health and mental health care services, in a drop-in setting. The center reports a 74 percent success rate in getting youths off the streets; of those youths that have been helped, 40 percent have been returned to their families and 60 percent have been placed in foster care, usually in the communities from which they originally came. The center also has a very strong AIDS education program, a critical issue because so many of the adolescents have become involved with intravenous drug abuse, prostitution, or both. In addition to the common element of being aimed toward specific subpopulations, many of these programs also exist as a result of joint public and private support. Some, such as the Nashville outreach program and the San Diego YWCA program, receive support from their state mental health agencies. Others, like Bailey House in New York and the

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HEALTH CARE SERVICES FOR HOMELESS PEOPLE 127 Folsom Street Hotel program in San Francisco, receive funding from municipal agencies. Still others, such as the Medeiros Center in Boston, receive funding from specific federal programs. Finally, some programs, such as the Larkin Street Youth Center in San Francisco, receive funding from several levels of government or, as is the case with the Volunteers of America outreach program in New York City, from specialized public authorities. What is noteworthy is that in each case additional resources have been forthcoming from the charitable sector, representing a true public and private cooperation. OTHER ISSUES IN HEALTH SERVICES FOR THE HOMELESS Coordinated Efforts in Non-,Iohnson-Pew Cities In addition to inquiring into cities that have received grants from the Johnson-Pew Health Care for the Homeless project, the committee sought information as to how health and mental health care is being provided to the homeless in cities that did not receive such grants. Site visits were made to three cities that applied for the grants but that were not funded (Kansas City, St. Louis, and San Diego) and one city that, because it was not among the 50 largest, was not eligible (Lexington, Kentucky). Returning to the four elements that appear to be common throughout most programs providing treatment to the homeless, the committee was able to make several observations. Communication Notwithstanding the lack of specific funding for health care programs for the homeless, each of the four cities evidenced effective communi- cation networks. Even though Kansas City and St. Louis were not successful applicants for the grant funding, the coalitions that were developed during the preparation of their applications continue in exist- ence. This enabled the process of communication developed for the grant proposal to proceed further; each city chose to attempt (with some success) to implement the original grant proposal with other sources of funding. In San Diego there have been several successive coalitions and task forces that have enabled communication networks to expand, often with the city and the county governments taking an active role. In Lexington, which was not eligible to apply for a grant and therefore did not specifically need a broad-based coalition for this purpose; such a coalition exists nonetheless because of close cooperation among provider agencies and a very supportive municipal government.

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128 HOMELESSNESS, HEALTH, AND HUMAN NEEDS Coordination Partly because they decided to proceed along the lines of their original grant proposals, Kansas City and St. Louis have achieved a reasonable level of coordination of services. In Lexington, in part because of its small size (population of approximately one-half million), coordination is less formal, but no less effective. San Diego, on the other hand, faces a serious problem arising from a separation of areas of responsibility mandated by the state of California: the county has responsibility for health care, mental health care, and social services and the city has responsibility for housing and public safety. Although the Johnson-Pew grant has enabled two other California cities (Los Angeles and San Francisco) to overcome this problem to some extent (especially in San Francisco, which has a combined city and county government), San Diego still faces serious problems of coordination of services. - , ~ , ",7 Targeted Approaches Each of these cities attempted to develop targeted services, especially health care services. Lexington has placed services for the homeless in one area in the downtown section of the city. St. Louis has residential programs near the psychiatric hospital that serves many chronically mentally ill homeless people. Kansas City is currently attempting to target services to homeless families, a problem that appears to be exacerbated by the economic decline of the surrounding farm communities. The San Diego County Department of Health Services has recently provided solme funding for a clinic operated in the downtown area in which homeless people tend to congregate. None of these cities, however, has been able to develop the kind of specialized services that are provided by many of the Johnson-Pew projects. Funding In three of these four cities, attempts to provide health care services to homeless people have been with joint public and private funding, with the bulk of the public funding coming from the city governments. In San Diego, however' the health care programs are mandated to the county _ . . . _ .. .. .. .. . . . - .- . . ~ .. government, with the result that program locations are distant from the - areas where homeless people are found, transportation is difficult to obtain, and it is time-consuming to travel to the programs; these are serious barriers to access. The experiences of these four cities support the fact that specific efforts are needed to deliver health care services to the homeless and to earmark

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HEALTH CARE SERVICES FOR HOMELESS PEOPLE 129 funds for such efforts. Even where programs do exist for homeless people, the lack of access and the absence of a targeted effort may vitiate them. Range of Health Care Services The experience of the Johnson-Pew projects and other providers of health care services for homeless people suggests that a wide range of services is needed. The range and the extent to which each service should be developed in a given city may be based upon such factors as the numbers of homeless people and the proportions of the various homeless subpopulations. An assumption of these health care services is that provision of social services is an integral component of health care. Although many of these services are appropriate for all people (homeless or not) and are especially important for the medically indigent, they are of even greater importance to homeless people because of the high level of debilitation seen in that population. The following range of services could be considered basic primary health care for homeless people. 1. Outreach to people where they are, including the streets. 2. General medical assessment and treatment for chronic and acute illnesses. 3. Specific screening, treatment, and follow-up for such health problems as high blood pressure. 4. Pediatric services (including well-baby clinics, immunizations, and screening for lead poisoning) and diagnostic and psychosocial intervention programs for both preschool and school-age children to address emotional disability and developmental delays. 5. Ancillary services (dentistry, podiatry, optometry, and specialized diets). 6. Access to mental health care and substance abuse services, including access to specialized housing. 7. Referral and access to convalescent care, as well as long-term medical and nursing care for catastrophic illness. 8. Gynecological services. 9. Prenatal care. 10. Educational services, primarily with regard to family planning and the prevention of sexually transmitted diseases (including the free distri- bution of condoms as part of AIDS education efforts). Any health care providers also should take into consideration special- ized mental health and substance abuse services. Unfortunately, health, mental health, and substance abuse have traditionally had separate funding streams, even though all three can interact with each other. This often blocks the delivery of services to people with multiple diagnoses. Models

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130 HOMELESSNESS, HEALTH, AND HUMAN NEEDS for the treatment of dual or multiple diagnoses for homeless people are rare (the Prevention Research Center in Berkeley, California, is currently researching the limited models of services for homeless substance abus- ers). The fact that they do not exist in great numbers does not, however, indicate that there is not a great need for such services; all reports received (both from the literature and from the site visits) suggest just the opposite. Discharge Planning Discharge planning is a difficult and complex task at best. General hospitals, mental hospitals, mental retardation facilities, correctional facilities, and the foster care system often are remote from the community into which the person is being discharged. However, all of these service providers are mandated to develop discharge plans for each client or patient, and even the best of plans can break down. Often, there is no follow-up to determine whether the plan works, and there can be an almost total lack of communication and coordination among institutions, communities, and the income support and service systems. The core of the problem, however, is that there are not enough options available on discharge. Acute-care hospitals are discharging people earlier, and home- less people have no adequate place to recuperate. There are only a few facilities that are minimally comparable to Christ House in Washington, D.C., and one cannot discharge a homeless person to home care if there is no home. It is true that there are insufficient appropriate options for discharging homeless people from acute-care hospitals; but networks of institutional providers, community-based service providers for the home- less, and the public social welfare offices could at least facilitate a more appropriate discharge than to the streets or to an inappropriate shelter. It is also highly desirable that shelter providers set aside beds that could be used for infirmary care or convalescence. Similarly, mental health programs could plan for discharging homeless people to a supportive living residence with an appropriate level of care. The short supply of such programs makes it difficult to develop discharge plans, but more extensive planning before and follow-up after discharge might prevent a significant number of failed placements. Correctional facilities and parole officers could better coordinate and monitor more intensively an individual immediately following discharge, when that person is most likely to be unemployed and is at a higher risk of becoming homeless. As noted previously, however, the lack of a full range of community-based placements is the worst problem in discharge planning, so that clients, patients, or ax-prisoners are thwarted from achieving the most independent level of functioning of which they are capable.

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HEALTH CARE SERVICES FOR HOMELESS PEOPLE 131 One seemingly critical issue relates to the preparations for the discharge of an individual who may be eligible for Supplemental Security Income benefits. Although it is not adequately publicized, the Social Security Administration does have a program for early predischarge application and review, primarily directed to those in psychiatric inpatient facilities (U.S. Congress, House, Committee on Ways and Means, 19871. Every effort should be made to utilize this program so that disabled people who might be eligible for SSI could conceivably have the application approved concurrently with their discharge. Unfortunately, the Social Security Administration does not yet have a procedure for early application and review. Case Management Over the course of this study, the committee heard repeated references to case management. During its site visits, the committee met and spoke with a number of individuals identified as case managers. These people came from a wide variety of backgrounds, including social work, psy- chology, nursing, and in one instance, from the ranks of the homeless themselves. How one views case management often seems to depend on the viewer's own past experience with the case management process, both personal and professional. Some see case management as the critical link that determines the success or failure of a program. Others see case managers as just another level of organizational bureaucracy that serves as still another barrier to the access of services. The major problem appears to be that case management is ill defined and the role of the case manager is inadequately described. Fortunately, during the course of this study two publications were released that sought- from very different approaches to resolve this problem. The Task Force on Welfare Prevention of the National Governors' Association (NGA) has released a report (1987) on welfare reform, Productive People, Productive Policies, that views the role of case management and case managers in terms of all human services. The COSMOS Corporation, under contract with the National Institute of Mental Health, has published a report, Intensive Case Management for Persons Who Are Homeless and Mentally Ill (Andranovich and Rosenblum, 19871. These two reports together provide a wealth of information for anyone who wishes to read a detailed analysis of this process and for those who work with homeless people. The COSMOS report presents the following definition of case manage- ment: Case management, as a mechanism for facilitating the access and movement of an individual through fragmented service systems, is viewed as an essential

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132 HOMELESSNESS, HEALTH, AND HUMAN NEEDS feature for effective service delivery to individuals who are homeless and seriously mentally ill. It attempts to ensure that a community support system is maximally responsive to the specific, multiple, and changing needs of individual clients. Both the NGA and the COSMOS reports identify similar functions that constitute the structure of case management: identification and outreach- determining who is in need of services and bringing them into the service delivery system; assessmentdetermining the client's individual strengths and deter- mining the needs that must be met; service planningdeveloping a plan to meet those needs; coordination and facilitationworking with the client and service providers to arrange for the actual delivery of services necessary to meet those needs; monitoring working with the client and service providers to deter- mine whether each service provider (or all service providers, if there is more than one) is meeting its obligations; evaluating determining when and if changes in the service delivery plan are necessary and then negotiating and monitoring the implementation of those changes; and advocacy acting for or with the client in obtaining those services (including housing) that are needed, with one of the ultimate goals being that the client eventually becomes his or her own advocate. The COSMOS report also identified "intensive" case management as critical to working with chronically mentally ill homeless people. It defined intensive case management as a more aggressive approach for those most in need, especially in the areas of outreach and advocacy. In addition, the NGA report speaks to the need for certain qualities in those who are case managers: communication skills, both with the client and with service providers; knowledge of such things as rules, regulations, programs, and resources; empathy with the client and the ability to assist in seeing the client's strengths and to capitalize on those strengths; ability to identify the critical issues facing the client and to identify the appropriate resolutions for those issues; and ability to hold others both the client and the accountable for their performance. Liability Insurance Coverage for Providers service providers- The committee received several reports of programs that have encoun- tered difficulties in obtaining malpractice insurance. Part of the problem

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HEALTH CARE SERVICES FOR HOMELESS PEOPLE 133 may be that the programs are based in social service agencies rather than in health care facilities, but the committee is unaware of instances in which legal judgments have been rendered in favor of a homeless plaintiff in a malpractice action. Therefore, the basis for setting extraordinarily high premiums for or denying malpractice insurance is unclear. The committee also received reports that several not-for-profit organizations lost their liability insurance coverage or were charged very high premiums, causing them to either suspend or curtail operations for extended periods of time. At present, these reports appear to be scattered and do not seem to represent any specific pattern of denial of coverage. The potential negative impact of the loss of insurance coverage on the ability of the private sector to continue to provide services to homeless people cannot be ignored. The potential lack of insurance coverage is of special concern with respect to the growing involvement of universities (especially medical, dental, and nursing schools) in the provision of health care services to the homeless. The committee observed the involvement of the schools of nursing of the University of Kentucky in the programs for the homeless in Lexington and of the University of California, Los Angeles, in the Johnson-Pew project in Los Angeles. In addition, the committee is aware of similar programs with the Johns Hopkins Medical Institutions in Baltimore and the Georgetown University Dental School in Washington, D.C. Problems with insurance both malpractice and general liability- could effectively forestall such efforts. Personnel Staff recruited to work with homeless people often have some special characteristics as well as professional expertise: They are willing to work against all kinds of odds and to provide services where the people are, leaving behind the more traditional and protected clinic and office settings. The ability to be innovative and flexible is important for working with the homeless. Staff may be open to the development of techniques that are different from those of the academic medical model and the usual adult outpatient clinics. The treatment of health problems is complicated by all the psychosocial problems experienced by homeless individuals and families. Some clients may be distrustful, rejecting, or hostile. The problems presented may often overwhelm the best trained, most expe- rienced workers. Many of the adaptive, creative responses that homeless people develop for coping on the street may work against their being moved into a domiciled situation. Making such changes and adaptations may be overwhelming and frightening for homeless people to contemplate. Finding the innovative approach to engaging such clients and motivating

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134 HOMELESSNESS, HEALTH, AND HUMAN NEEDS them to try changes is the ultimate challenge of professionals who work with homeless people. Of central importance to the task is each staff member's commitment and willingness to work as a part of an interdisciplinary team in which there is distinct professional expertise but also some fluidity in roles. In addition, although it is unlikely that anyone would be attracted to working with homeless people for material reasons, too often the salaries that are offered reflect society's tendency to stigmatize the workers in the same manner as it stigmatizes homeless people. Salaries can be made com- mensurate with work load and experience as well as competitive in the employment market. Specific and appropriate training of staff is desirable. Some staff may already have worked with homeless people but not in the context of health care services; others may be health care workers who have not worked with homeless people. Still others may have worked with a different population of homeless individuals. Training might include: issues relating to the homeless, for example, the causes of home- lessness, the subpopulations, and the health problems of homeless people; ~ orientation to the agency, including its policies, procedures, and opportunities for staff development; supervision, including the medical and social service aspects of the program; interview techniques or other means of assessing emotional problems; crisis intervention techniques; problems of working with the chronically mentally ill; identification of and strategies for confronting manipulative behav- iors; and issues of case management, for example, other resources that are available and how a homeless person can access those resources. SUMMARY Although homeless people are a diverse group, the nature of their life situations and the multiplicity of their needs lead to the conclusion that they would benefit from specific approaches in the provision of health and mental health care services. Programs have been targeted to the homeless in general; specific programs have been targeted to certain subpopulations that are delineated by the nature of their health problems, demographic characteristics that necessitate specialized approaches, or their location, such as in rural and suburban areas. Even when such specialized services are provided, the coordination of efforts with other existing services is essential. The goal should be to enable homeless people to have access to the range of services that already exist, thereby

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HEALTH CARE SERVICES FOR HOMELESS PEOPLE 135 decreasing their need for specialized services. The ultimate goal is to resolve whatever problems prevent homeless people from becoming domiciled. REFERENCES Andranovich, G. D., and S. Rosenblum. 1987. Intensive Case Management for Persons Who Are Homeless and Mentally Ill. Washington, D.C.: COSMOS Corporation. Bargmann, E. 1985. Washington, D.C.: The Zacchaeus Clinic A model of health care for homeless people. In Health Care of Homeless People, P. W. Brickner, L. K. Scharer, B. Conanan, A. Elvy, and M. Savarese, eds. New York: Springer-Verlag. Breakey, W. R. In press. Mental Health Services for Homeless People. In Homelessness: A National Perspective. M. Robertson and M. Greenblatt, eds. New York: Plenum. Brickner, P. W., L. K. Scharer, B. Conanan, A. Elvy, and M. Savarese, eds. 1985. Health Care of Homeless People. New York: Springer-Verlag. Clark, M. E., R. M. Neal, S. L. Neibacher, and S. L. Wobido. 1985. A flexible approach to health services for the homeless: The National Health Care for the Homeless Program. Paper presented at the Annual Meeting of the American Public Health Association, Washington, D.C. Fischer, P. J., and W. R. Breakey. 1986. Characteristics of the homeless with alcohol problems in Baltimore: Some preliminary results. Department of Health Policy and Management, School of Hygiene and Public Health, and Department of Psychiatry and Behavioral Sciences, School of Medicine, The Johns Hopkins University, Baltimore, Md. Goddard-Riverside Community Centers. 1986. Project Reachout: Services and Advocacy for the Mentally Ill Homeless. New York: Goddard-Riverside Community Centers. Greater Boston Adolescent Emergency Network. 1985. Ride a Painted Pony on a Spinning Wheel Ride. Boston: Massachusetts Committee for Children and Youth, Inc. Lamb, H. R., ed. 1984. The Homeless Mentally Ill. Washington, D.C.: American Psychiatric Association. Robertson, M., and M. Greenblatt. In press. Homelessness: The National Perspective. New York: Plenum. Rosenheck, R., P. Gallup, C. Leda, P. Leaf, R. Milstein, I. Voynick, P. Errera, L. Lehman, G. Koerber, and R. Murphy. 1987. Progress Report on the Veterans Administration Program for Homeless Chronically Mentally Ill Veterans. Washington, D.C.: Veterans Administration. Task Force on Welfare Prevention, National Governors' Association. 1987. Productive People, Productive Policies. Washington, D.C.: National Governors' Association. U.S. Congress, House, Committee on Ways and Means. 1987. Background material and data on programs within the jurisdiction of the Committee on Ways and Means. 100th Cong., 1st sees., March 6, 1987.