EXECUTIVE SUMMARY

Programs that include healthcare organizations collaborating with homeless shelters and agencies need organizational plans.

• A first step is to identify the population that will be targeted for services.

• Next, create a process, committee, or panel to make decisions about how the housing resources can best be used.

• Third, work with communities to provide preventive care and primary care services and to meet homeless clients’ other healthcare needs.


Communities across the country are working to reduce or end chronic homelessness. They are focusing on ways the government, nonprofits, and healthcare providers can work together on solutions that benefit all.

For example, Bergen County in New Jersey ended chronic homelessness in 2017, a decade after beginning a comprehensive Housing First project. In Chicago, a large urban health system has successfully reduced homeless patients’ ED visits by focusing on helping them find permanent housing. Following Hurricane Katrina, New Orleans reduced homelessness by 90%. (More information is available at: https://wbur.fm/2HJPueu.)

Also, Kaiser Permanente pledged $200 million in May 2018 to support affordable housing for homeless people. (Find out more on the initiative at: https://k-p.li/2U94hB6.)

The following are some of the strategies employed in Chicago and Bergen County:

• Identify chronically homeless patients. The University of Illinois Hospital and Health Sciences System in Chicago began its program to find housing for homeless patients with nurses’ help, says Stephen Brown, MSW, LCSW, director of preventive emergency medicine, department of emergency medicine at the University of Illinois Hospital and Health Sciences System. (See story in this issue about how housing centers can lead collaborative effort.)

“Our charge nurses know every homeless individual,” he says. “We came up with an initial list of 48 individuals.”

Now, the program uses data-mining and other methods to identify ED and hospitalized patients who are chronically homeless.

“Last year, we had 1,240 individuals who are currently homeless in our system,” Brown says.

Using the hospital’s electronic medical record, the program added a column that notes how many times a patient has visited the ED in the previous four months. This is considered a risk factor for homelessness, he adds.

“I developed a list of the most frequent utilizers, and we looked at their charts,” Brown explains. “We might see that their address is a crisis shelter, and we look in the clinical notes to see whether they are homeless, undomiciled, or living on the streets.”

Then the list is circulated to social workers, ED doctors, residents, nurses, and psychiatrists.

• Create a panel to assess patients for intake. With a long list of homeless patients, the program needed to focus on those who were chronically homeless.

“They were too challenging, so we needed to do a group decision,” Brown says. “We developed a chronically homeless referral panel, whose job is to assess patients for the housing program.”

The panel invited staff to present cases they believed needed the program, and there would be three to five cases assessed at each monthly meeting, he says.

To qualify for the program, the patient must be chronically homeless. They defined this as someone who had been homeless continuously for at least one year or someone who experienced four episodes of homelessness within the previous three years.

The panel’s meetings would last one hour to 1.5 hours and involve back-and-forth questioning.

“We had some challenging conversations,” Brown says. “One homeless person lived in a storage locker, paying $100 a month for the unheated space with no sanitation.”

But when that case was compared with homeless people who were experiencing frostbite from living on the streets, it was decided that the latter individuals were suffering more health-wise and better met the definition for chronic homelessness, he explains.

In another case, a woman was about to start breast cancer treatment, but she didn’t qualify as chronically homeless because she had only been homeless for eight months.

“So we didn’t put her in the program,” Brown says. “Eventually, we got her in a medical respite program where people go to convalesce.”

“We never excluded people from the program,” Brown adds. “We helped a sex offender, and it took us three-to-four months, and we never found anything in the city, so we had to broaden our search to the suburbs.”

The man had to be interviewed by a local police department, but he eventually found permanent housing.

These kinds of decisions are terribly difficult, he notes.

• Involve outreach workers, primary care, preventive care, and community providers. The project to end homelessness in Bergen County has benefited tremendously from an integration of services, says Julia Orlando, CRC, EdM, MA, director of the Bergen County Housing, Health, and Human Services Center in Hackensack, NJ.

Homeless patients with medical and/or behavioral health issues are increasingly receiving healthcare when they need it. Also, there are more conversations between homeless organizations and health providers about discharge planning, Orlando says.

Before the integrated approach, homeless patients would receive hospital treatment for a medical condition — but not the psychiatric care they also needed. Since the focus on ending homelessness, these individuals are receiving all needed healthcare services, including detox and substance use treatment in one of the local hospitals, she explains.

“If they don’t have medical insurance, they can apply for charity care,” Orlando says. “One of us will call the hospital and say that ‘So-and-so is coming over, here’s the profile, here’s what’s going on with them.’”

This ensures healthcare providers know everything they need to know about each patient.

“Soon, we will have integrated medical records and will share information [electronically],” Orlando says. “When that happens, it will be a game-changer.”

The homeless shelter opened a health clinic in September 2018 to provide preventive care and reproductive health counseling, says Noemi Dominguez, RN, MSN, director of public health nursing at Bergen County Department of Health Services.

With state funding for the Access for Reproductive Care and HIV (ARCH) program, the health clinic is located in a homeless shelter to provide care for people waiting there for permanent housing, she says. (Find out more about ARCH at: https://bit.ly/2TZXLNh.)

“Our objective is to reduce harm,” Dominguez says. “We’re not only serving the homeless population, but also reproductive-age men and women, and high-risk populations like addicts and sex workers.”

The clinic’s location within shelters is comfortable for its target clients, she notes.

“We collaborate with other agencies to provide STD screening and nutritional counseling,” Dominguez says. “We do sexual and reproductive health counseling, pregnancy testing, vaccinations, wound assessment, HIV care, [and] pregnancy care, and we reach out to IV drug users to reduce self-harm.”

The clinic has four exam rooms, two nurses, an outreach worker, and a phlebotomist. They see residents of the shelter, as well as walk-ins, she says.

“In January 2019, we had 188 visits, and we average 100 visits with the wellness nurse per month,” Dominguez says. “Sometimes, we can change the behaviors.”

The clinic connects clients with primary care services, behavioral health services, and insurance, as needed.

“Our goal is to empower people to have a home and to manage their illnesses,” Dominguez explains. “Right now, we’re in the process of developing an outreach program to find sex workers and IV drug users that are very hard to reach because their behavior is taboo and they’re hidden.”

At the University of Illinois Hospital and Health Sciences System, social workers help patients schedule an appointment for when they leave the hospital, and they contact housing case managers to ensure patients are taken to the appointments.

Alignment with community providers includes working with mental health programs, as the homeless population has high rates of mental and behavioral health problems. (See story on treating mental health issues of homeless patients in this issue.)

Housing case managers reach out to primary care providers, making it easier to navigate patients into more appropriate levels of healthcare.

“These housing case managers would help set up medical appointments and get them to their appointments,” Brown says.

“These folks are already very ill and rely on services with multiple specialists. You see a high rate of comorbidities of this population,” he explains. “We try to get people into primary care, but most of the engagement we have is getting them into seeing their specialist.”