Health Care For The Homeless
COLLABORATING FOR ACCESS TO INTEGRATED HEALTH CARE
Visualize a system of care that welcomes homeless families and individuals with services focused on their special needs. Imagine that people can access primary health, substance abuse and mental health services, and shelter wherever they are in the county, and obtain a medical home for consistent treatment of chronic conditions. That’s what the clinics, hospitals, and homeless services participating in the Health Care for the Homeless (HCH) Collaborative are doing. The Collaborative is creating a visual map of integrated health care services.
Chaired by Dory Escobar of St. Joseph Health System Community Benefit Division and facilitated/staffed by the Georgia Berland of the Task Force for the Homeless, the HCH Collaborative is assessing the network of health resources available to homeless people, over 70% of whom traditionally receive only episodic care at hospital emergency departments, clinics, or mobile clinics. Through a geographical map of services and linkages including transportation, the group is identifying service and resource gaps and working to close them by coordinating more closely and/or garnering resources cooperatively. Our members have constructed scenarios of clients facing difficult and complex barriers to care. At each monthly meeting, the group walks through one or more scenarios using our service map, sharing ideas and resources on how best to serve the client, and identifying areas where further coordination is needed.
The HCH Collaborative now includes representatives from clinics and/or homeless services in every district in the county. It also includes Memorial, and Sutter Hospitals (both of which were involved in establishing and developing the Collaborative, along with County Mental Health, Alcohol and Other Drug Services, and Public Health.. It has added new or enhanced health services for homeless people in West County, Santa Rosa, and Petaluma.
In addition to identifying and closing service gaps, the HCH Collaborative is now designing standards of care specific to homelessness, as well as integrated interdisciplinary case management, and patient-centered systems to share information across health, mental health, substance abuse and homeless services by June 30, 2009. We’ve identified some excellent national and local models for the standards of care and patient information systems that we could adapt to our needs, and have already begun the design of the integrated case management system. We have active committees working in each area, and reporting at each monthly meeting of the full Collaborative.
The Collaborative has added new services to address unmet needs in Santa Rosa, helping to solidify the Santa Rosa Homeless Clinic and to make the connection with Southwest Community Health Centers, of which it has now become a satellite. In West County, a new Family Nurse Practitioner is offering the first services targeted to homeless clients in this underserved area. In Petaluma, a homeless intern is driving patients residing at the Mary Isaak Center of the Committee on the Shelterless (COTS) to collateral medical and dental appointments. All of this work is currently supported by a $33,000 grant from the Sisters of St. Joseph Healthcare Foundation. Sterling (Sonoma) Bank granted the Task Force an additional $1000 to help facilitate the process. We are applying for additional funds to assure implementation and ongoing refinement of the systems we are now constructing.
As our interagency and interdisciplinary connections and systems grow, doors will open wider to homeless people in need of care. The integrated support services we are working to establish will help them to build healthier, happier lives.