Oakland County is located in Southeastern Michigan, just north of Detroit, and consists of 910 square miles. The Oakland County Health Division (OCHD) serves the county population of 1.2 million.In 2011, data from OCHD’s Nurse on Call Resource Hotline showed an increasing number of requests for information regarding low/no-cost healthcare and prescriptions, resources for food, shelter and mortgage foreclosure assistance. We also received information from community partners about an increase in the number of persons requesting services because they were homeless.
OCHD conducted a community assessment to find out more about the persons who were experiencing homelessness, their health needs and what services could be used to support to them. That assessment found gaps and barriers between agencies providing the needed services and the client. Service providers were also often unaware of other available resources and, at times, unsure how to access them for their clients.
OCHD convened representatives from local agencies, health providers, and others who offer resources and services to the homeless and vulnerable populations of the county to form the Homeless Healthcare Collaboration (HHC). The purpose was to ascertain and connect existing resources in the community while identifying and exploring ways to minimize gaps and barriers experienced by both consumers and service providers.
Health care was identified as an area where barriers to care for the homeless and vulnerable are experienced by both the client and the provider. Clients have difficulty accessing and coordinating community medical care, treatment, and follow-up, instead utilizing the emergency room as their medical home. Service providers identified the need for more knowledge of available community resources and how to organize services to better serve this population.
The objectives of the HHC are:
Identify the barriers that exist for homeless/vulnerable clients in accessing health and wellness services.
Identify the barriers that prevent and limit healthcare providers from serving the homeless/vulnerable population.
Educate HHC members about existing services that meet the needs of their clients.
Provide a secure, online forum where information and resources can be shared among HHC members.
Establish sub-committees as necessary that address specific concerns, such as discharge planning for hospitalized persons who are homeless.
Presentations by member agencies at regular Homeless Healthcare Collaboration meetings educate the group about how they are able to serve their clients. A secure electronic portal has also been developed by OCHD where collaboration members can post information, ask questions, and share resources.
Several sub-committees of the collaboration have been established to address some specific issues. The Hospital Discharge Task Force, which includes representatives of local hospitals, is addressing the unique and difficult issues surrounding hospitalization and discharge planning for clients who are homeless. The Identification Task Force is working with State and local government agencies that issue official identification to overcome the barriers experienced by persons experiencing homelessness in obtaining proper identification.
OCHD serves the entire county which is home to 1.2 million people and located just north of Detroit. It is a geographically large county of 910 square miles and contains urban, suburban and rural areas. Due to the many auto manufacturing plants and related businesses located in the region, the recession had a severe economic impact on Oakland County. As stated in County Executive L. Brooks Patterson’s 2010 State of the County Address, the unemployment rate reached a high of 15.6 percent in 2009. Between 2000 and 2010, the poverty rate in Oakland County increased by over three percent. According to the Consolidated Annual Performance and Evaluation Report done by Oakland County Community and Home Improvement, foreclosures in the county increased by 1000 percent from 2000-2012.These economic conditions increased the number of people at risk for homelessness in Oakland County. In 2011, the number of persons known to be sheltered or on the street in Oakland County was 2,847. Those experiencing homelessness for the first time was 1,309, which was an increase from 796 in 2010.
Calls received by the OCHD Nurse on Call (NOC) program from individuals who were unemployed or uninsured increased by almost 60 percent in 2011 compared to 2010. There were similar increases in the number of requests for information and referral to resources for low/no cost healthcare, food pantries, and assistance with foreclosure and eviction. In 2011, colleagues at the Intermediate School District noted that there was a 60 percent increase in number of students who were homeless over the previous year. Community agencies indicated that more people were seeking shelter, and shelter staff reported an increase in the cases of frostbite and amputations due to cold weather exposure.
As OCHD began to look at the increasing population of homeless and vulnerable persons in our jurisdiction, the initial plan was to survey the community agencies on resources available and educate about Health Division services. In the past, OCHD served this population by providing resource information, immunizations, communicable disease screening, and substance use disorder services, as requested. As our assessment continued, it became clear that client needs went beyond what OCHD alone was able to offer. To work toward the goal of health promotion and disease prevention for this population, the collective knowledge of the many providers that work with the homeless and vulnerable population needed to be pooled.
The community assessment marked the beginning of a collaboration that promises to change the way our community partners work together. Cooperation exists that likely otherwise would not have taken place, and the relationships established and knowledge exchanged through the Homeless Healthcare Collaboration have already begun to show results.
The collaboration is an impressive demonstration of a local public health agency actively identifying a community need and engaging stakeholders in developing strategies to address specific needs of the population. Specific achievements include:
Teamwork among public health and other community providers to coordinate services to effectively meet an identified community need.
Harnessing existing technology to facilitate communication between community partners and share information about available services.
Improved service delivery due to increased provider understanding about resource availability and eligibility.
Other public health agencies would be able to replicate and adapt this effort in their own communities to address the needs of the homeless and vulnerable populations. The process has improved how we work together with both outside service providers and other departments within Oakland County. Through the knowledge gained as a result of this initiative, we are more aware of the needs of county residents and what resources are available to serve them.
OCHD is improving our customer service as a result of information gained from HHC. Several internal barriers that would have prevented these clients from accessing services have been removed. OCHD introduced a sliding scale for clinic service fees and homeless clients are given cards that would allow the $5 clinic fee to be waived. Clinic support staff have been given sensitivity training for homeless clients, such as not to press for picture ID, address, and/or financial information.Connecting clients to previously unknown resources affirms the importance of the HHC. Service providers in Oakland County have developed a renewed enthusiasm and commitment to improving client health and well-being as a result of the collaboration.
In late 2011, OCHD committed a full-time Public Health Nurse to establish regular visits at local shelters and community agencies. The nurse conducted a community assessment to more fully understand:
The extent of homelessness
The health needs of persons experiencing homelessness
Existing resources that were available to serve their need
Barriers and gaps to accessing and providing healthcare.The Public Health Nurse was also able to assess the knowledge of the community agency staff and their clients about what was available to meet their needs.
Face-to-face interviews were done with agency staff and guests at shelters, warming centers, and nutrition sites throughout the county.
Community agency staff shared their experiences in trying to provide services and access resources.
Resources were shared and referrals were made as needed.
Assessment findings included:
Community agencies were unaware of healthcare resources available in the county as well as other assistance offered by different providers.
Homeless and vulnerable clients were using emergency department for non-emergent conditions and subsequently contributing to the high cost of care.
Homeless and vulnerable clients receive limited follow-up care and prescriptions which contributes to a higher rate of complications. This in turn necessitates a return to the ER for care, admissions for further treatment and more uncompensated care.
Homeless and vulnerable clients often have difficulty accessing services for basic needs and healthcare.
Lack of insurance, transportation, money, and proper identification contributed to the difficulty in accessing preventive services or follow-up care
Even the OCHD’s clinic service fee of $5.00 was identified as a barrier to care and immunizations for this at-risk population.
In August 2012, the OCHD engaged representatives from local agencies, healthcare providers and others who provide resources and services to homeless and vulnerable population to form the Homeless Healthcare Collaboration (HHC). The purpose of HHC was to ascertain and connect existing resources in the community, identify gaps and barriers experienced by both consumers and service providers, and develop strategies to minimize them.
During that first meeting, interested agencies and service providers discussed the barriers to receiving assistance experienced by homeless clients and giving assistance by those service providers. Two scenarios were described that provided participants the opportunity to identify where roadblocks occurred. After a group discussion, over fifty barriers and gaps to service were identified, including both difficulties experienced in accessing services and barriers to providing services.
Healthcare was identified as an area where barriers to care for the homeless and vulnerable are experienced by both the client and the provider. Clients have difficulty accessing community medical care, treatment, and follow-up, instead utilizing the emergency department as their medical home. Healthcare for vulnerable populations could be improved by ensuring that service providers have a better understanding of existing community resources and how to coordinate these assets.
The HHC members worked together to develop objectives for the group:
Identify the barriers that exist for homeless/vulnerable clients in accessing health and wellness services.
Identify the barriers that prevent and limit healthcare providers from serving the homeless/vulnerable population. • Educate HHC members about existing services that meet the needs of their clients.
Provide a secure, online forum where information and resources can be shared among HHC members.
Establish sub-committees as necessary that address specific concerns such as discharge planning for hospitalized persons who are homeless.For clients, the most frequent barriers to care included the lack of stable housing, inability to obtain official identification, limited or no income, and the lack of ongoing medical care. Other contributing factors included lack of transportation, mental health diagnosis, poor organizational skills, and no health insurance. For providers, the most frequent barriers to providing care included limited funds, lack of compensation, insufficient knowledge of other community resources, inability to serve medically needy clients after discharge, and restricting rules and regulations such as minimum fees and geographic limitations on service.
HHC developed specific processes and task forces to investigate and/or address barriers identified through the community assessment. To address the identified barrier of lack of knowledge about service provision, OCHD established and hosts a secure web-based portal to share information among partners. The portal is available only to HHC members and allows members to communicate with each other about service provision for specific clients. Information on the HHC Portal is sustained and updated by cooperation with community partners.
Hospital providers in the county voiced great concern when confronted with the difficulties of discharging patients who are homeless. Discharged patients frequently require ongoing wound care or treatments, prescription medication and a place to recover. Lack of stable housing can cause clients to return to the emergency department due to an exacerbation in their illness. The Hospital Discharge Task Force, a sub-committee of the HHC, explores strategies to address these issues. The Hospital Discharge Task Force includes representatives of hospitals, shelters, health care providers, housing services, and Health Division staff. Locating available resources and connecting clients with benefits and housing are key components of the subcommittee’s work.
Long-term goals of this task force include:
Develop plans to provide case management for frequent users of emergency department services.
Create a community respite facility where medically fragile patients without stable housing could receive follow-up care. This would reduce complications such as infection and readmissions to the hospital.
Another barrier to service that was noted to be a significant problem for clients experiencing homelessness was obtaining official identification. Several members of the collaboration now meet to address these issues facing clients. The Identification Task Force is working with state and local government agencies that issue official identification to overcome the barriers faced by persons experiencing homelessness in obtaining proper identification. Talks are underway at the county level to make obtaining a birth certificate more accessible for those without income. The Oakland County Clerk is in the process of developing a draft proposal to change fees for getting a birth certificate.
Development of the HHC has improved OCHD services as well. Following a presentation from veteran’s services regarding eligibility requirements for Veterans Affairs programs and services, NOC staff are now assessing the veteran status of each caller to provide important resources. Additionally, all fees are waived for homeless clients receiving Health Division clinic services, such as immunizations, and communicable disease testing and treatment. Agencies serving homeless populations are provided special business cards for clients to present at OCHD clinics. These cards prompt staff to automatically waive any fees associated with this client.Homeless Healthcare Collaboration meeting agendas are guided by the membership. A short survey is completed at each meeting to gauge learning, find out what was beneficial and elicit suggestions for subjects that they would like to know more about. Survey results are more than a formality. They drive the group direction. They can show our flexibility and responsiveness to the group and in collaborations it is the members of the group that sustain the effort. The suggestions given serve to create the agenda for the following meeting.
Feedback from Collaboration participants indicated that they valued the networking time as much as the education. Now, at the mid-point of each meeting, we take an extended break to include additional time for networking.
Through the HHC, OHCD has brought together shelters, medical providers, and service agencies to identify needs and develop strategies to improve access to housing and health services for the homeless and other vulnerable populations in Oakland County. Since its inception in August 2012, attendees at our bi-monthly meetings have grown from 29 persons representing 23 organizations to over 90 persons from 49 agencies. This collaboration is working together to improve care by expanding knowledge of resources, forging new partnerships, breaking down barriers, and exploring ways to deliver coordinated health care in the community to reduce emergency department usage.
The main cost associated with this program is the cost of a full-time Public Health Nurse which is $101,190 for salary and benefits. No new resources were required to utilize the communication portal. All community partners serve with the Collaboration on a volunteer basis.
The Homeless Healthcare Collaboration has achieved significant results in the short time since its initiation. Development of long-term or permanent solutions for the lack of housing and access to healthcare is in place for this population in Oakland County. Information and resources provided by the Michigan Department of Human Services (providers of Medicaid and other financial assistance to low-income clients) and Oakland County Veterans Services offered new ideas for care of homeless and vulnerable clients. Additionally, other local service providers have offered valuable resources to educate partners about the types of assistance available and how it is accessed.
As a result of the HHC meetings, 93% of attendees report they have formed a connection with another agency and 73% are reviewing, updating or changing policies and practice. The service knowledge and education of the group has also significantly increased. From evaluations at each meeting, reported attendee knowledge after each presentation has increased an average of 1.8 points using a five point Likert scale. Establishing this forum for members to share information about their specific services has facilitated collaboration among service providers on behalf of specific clients.
For example, a guest had a stroke while staying at Hope Hospitality, a cold-weather nightly warming center. She was transferred to a local hospital and admitted. The client was a poor historian, however she was able to say where she had been staying. The client signed a release of information and the hospital contacted the director of Hope on a daily basis. The director was able to supply key information that allowed the discharge planner to access housing and follow-up services (the client was a veteran). This connection between the discharge planner and Hope was a result of networking that took place at the Homeless Healthcare Collaboration.
Another connection made at HHC was between a local pastor who spoke with the PH Nurse about one of his parishioners. This man was sleeping under the stairs at the church building, using a cardboard shelter, in sub-zero weather. This man had a history of alcohol abuse and the pastor was concerned he would freeze to death or sustain serious frostbite. With the assistance of the Public Health Nurse and the Substance Abuse administrator, the man was placed immediately into a temporary shelter until he could enter the substance abuse treatment program he requested.
The Homeless Health Care Collaboration is an impressive demonstration of a local public health agency actively identifying a community need and engaging stakeholders in developing strategies to address the needs of persons who are homeless. The development of this collaborative has allowed OCHD and partners to:
Demonstrate teamwork among public health and other community providers to enhance services and effectively meet an identified community need
Leverage existing technology to engage community partners in sharing and obtaining information about available services
Provide better service for clients through increased provider knowledge about community resource availability and eligibility.
From an altruistic desire to improve the health and well-being of the homeless and vulnerable population to a financial interest in reducing health care costs, there is strong support to continue the collaboration. There is robust participant enthusiasm because they experienced firsthand these shared mutual interests and positive client results.A firm framework provided by OCHD is also in place to continue support for the initiative.
The Public Health Nurse position is supported by local general funds and is not subject the instability associated with external funding.
The total cost of the expansion of the service was $101,190; no other new resources were used for staff or technology
The web-based portal for use by Collaboration members is part of a larger system which is used by OCHD for regular communication with community partners such as schools, hospitals and emergency preparedness officials. This system is an integral part of OCHD operations.
As HHC continues its strategic planning process, evaluation and assessment of barriers to care for homeless and vulnerable clients remains a primary focus of the group. Continuing to evaluate and respond to the needs of the organizations that are voluntarily participating in this collaboration is a key component for sustainability. Through long term planning, flexible response to participant interests, and continued support from OCHD staff, the collective effort of HHC will continue to improve the healthcare coordination of the homeless and vulnerable population in Oakland County.