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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~.
Disaffiliation—Although 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:
Communication—Those 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 Approach—Programs 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 Resources—These 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;
· assessment—determining the client's individual strengths and deter-
mining the needs that must be met;
· service planning—developing a plan to meet those needs;
· coordination and facilitation—working 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.
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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.
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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
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Fischer, P. J., and W. R. Breakey. 1986. Characteristics of the homeless with alcohol
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Md.
Goddard-Riverside Community Centers. 1986. Project Reachout: Services and Advocacy
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Lamb, H. R., ed. 1984. The Homeless Mentally Ill. Washington, D.C.: American Psychiatric
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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
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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
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Cong., 1st sees., March 6, 1987.
Representative terms from entire chapter:
care services
