# Presentation: 260825

## Addressing the Health/Behavioral Health Needs of Homeless Families

- Frances E. Isbell, M.A.
- Executive Director
- Healthcare for the Homeless – Houston (HHH)
- Improving Access to Mainstream Services for Families with Children Experiencing Homelessness Policy Academy
- April 20, 2005

## Goals of Presentation

- Provide an overview of Healthcare for the Homeless – Houston, including the Women and Children’s Clinic
- Present innovative models of care
- Describe “lessons learned” and specialized needs of homeless women and families

## Brief History of HHH

- Originated in 1999
- Houston-area service agencies for the homeless formed a consortium dedicated to the provision of comprehensive, coordinated health care for the homeless
- Consortium developed the initial vision of HHH
- Incorporated as a nonprofit organization in 2000
- Deemed a Federally Qualified Health Center (FQHC), Health Care for the Homeless program in 2002
*Mission: to promote health, hope, and dignity for Houston’s homeless through accessible and comprehensive care*

## Unique Organizational Structure of HHH

- HHH is “governed” by 3 distinct groups:
- Board of Directors
- HHH Advisory Council
- Consumer Advisory Board (CHANGE Committee)

## Board of Directors

- Functions as a conventional governing Board of Directors
- Is compliant with governing regulations required by the Bureau of Primary Health Care
- 20% of Board members are elected representatives from the Advisory Council, which must include at least one homeless or formerly homeless person
- Includes a representative/liaison from the Consumer Advisory Board/CHANGE Committee

## HHH Advisory Council

- Developed from the original consortium that began to meet in 1999, currently includes 28 agencies
- Provides guidance in HHH strategic planning and program coordination
- Includes homeless/formerly homeless representatives, including a representative from the CHANGE committee
- Includes both public and private agencies
- Makes Houston one of the few cities to have a multiagency effort to develop and integrate healthcare services for the homeless

## HHH Advisory Council Agencies

| Aid to Victims of Domestic Abuse | Dept. of Veterans Affairs | Open Door Mission |
| --- | --- | --- |
| AIDS Foundation Houston | ECHOS | Palmer Way Station |
| ALTE Community Care Services | Harmony House | Harris Co. Public Health & Environmental Services |
| Angela House | The Housing Corporation | Salvation Army Harbor Light Center |
| Bread of Life | Houston Area Women’s Center | SEARCH |
| Brigid’s Hope | Houston Area Community Services | Shalom Zone Mobile Health Ministries |
| Cathedral Health Ministries | LifeOptions | Star of Hope Men’s Development Center |
| Coalition for the Homeless | Lord of the Streets | Houston Recovery Campus |
| Compass

De Madres a Madres, Inc. | MHMRA of Harris County

Montrose Clinic | Homeless/formerly homeless representatives
 |
|  |  |  |

## CHANGE Committee

- A consumer advisory board
- First convened October 2001
- Meets twice a month
- 3 original members continue
-       to participate
- Provides representation from
-       consumers to community
-       and HHH Board of Directors

- Front row from left: JR, Smitty, Cowboy, Tyrone
- Back: Staff

## HHH Programs

- Shelter Clinics: 3 primary care clinics located in shelter facilities
- Outreach: street, mission, and soup-kitchen outreach
- Student Clinic: student-run free clinic including medical, pharmacy, and public health students
- Women & Children’s Clinic
- Dental Clinic
- Research/Evaluation Program
- Transportation Program
- Annual Needs Assessment: HHH, with Baylor College of Medicine, conducts annual health needs assessment and gaps analysis for homeless men, women and families of Houston/Harris Co.

## Services Provided

- Primary care and outreach health care
- Behavioral health care (psychiatry; individual, couples, and family counseling; substance abuse assessment and treatment)
- Comprehensive dentistry
- STD and TB testing
- Podiatry
- Medical case management
- Vision assistance
- Healthcare education, information, and referral

## History of Women and Children’s Clinic

- A formerly homeless Board member began requesting a Women and Children’s clinic in early 2000, but the demand did not appear to warrant the expansion
- By the end of 2000, the ratio of women seeking health services had increased from <20% to >34%
- Year 2000 Needs Assessment identified the lack of women’s medical services as one of the top 5 gaps in Houston’s health services for the homeless

## History of Women & Children’s Clinic (Cont.)

- December 2000 – met with the HHH Advisory Council and other agencies serving homeless women to develop a referral system for the clinic
- February 2001 – opened a 1-day-a-week clinic at Lord of the Streets which offers a safe, confidential environment

## Significance of Homelessness and Health Care for Women and Families 

- Health care is a “luxury” homeless families cannot afford, especially given recent cuts in Medicaid
- Shelter, safety, and food are higher priorities than health care
- Clinic visits often mean loss of work, food, emergency shelter, or school time
- Domestic violence is the leading cause of homelessness for women and children; increased risk of physical, emotional, and mental trauma

## Slide 14

## Slide 15

## Primary Diagnoses of Adult Women

**Hypertension**
**Depression/mood disorder**
**Diabetes**
**Drug/alcohol dependence**
**Bacterial vaginitis**
**Allergic rhinitis**
**Dental caries**

## Primary Physical Diagnoses for Children

**Upper respiratory tract infections**
**Skin diseases**
**Ear diseases**
**Dental problems**
**Poor vision**
**Gastrointestinal conditions**
**Trauma-related injuries**
**Compromised immunization status**

## Traditional Models of Care

- Traditional care models do not work well with homeless patients
- Homeless people often reject help that is provided in conventional ways, i.e., physician determining treatment for patient
- Past negative experiences with health care institutions often reinforce sense of failure

## Shifting Focus

- Patient-centered
- Incorporate patient’s experience of illness, psychosocial context, and shared decision-making
- Goal-oriented
- Interact with patient to make clinical decisions and negotiate goals

## Adding Theory

- Shared goal setting results in more realistic appraisal and planning
-  **Self-efficacy =**  **Success**
- Increased self-efficacy may result in efforts to improve health and well-being
- Albert Bandura, “Self-Efficacy: The Exercise of Control.”  1997

## A New Paradigm: Goal-Negotiated Care (GNC)

- GNC is a solution-oriented approach
- Provider and patient work together to overcome barriers to care
- GNC impacts patient self-efficacy
- Leads to improved treatment and program adherence
- Patients begin to experience successful relationships

## Lessons Learned

- GNC is generally most effective with long-term care, allowing for accumulation of successful negotiations
- Homeless women and children, although more likely to be housed, are very “fluid” due to issues associated with domestic violence
- Long-term care most often occurs in areas of behavioral health counseling and dentistry, both scarce in city/county public health systems

## Lessons Learned (Cont.)

- Behavioral health care, in conjunction with primary care, essential in most, if not all, cases
- HHH currently offers psychiatry, individual and family counseling, parenting and anger management groups
- Homeless youth, especially unattached youth, have unique “problem sets”
- HHH cross-refers with a mobile health clinic with targeted patient population of homeless youth, ages 16-24

## Lessons Learned (Cont.)

- Women & Children’s Clinic has reduced utilization rates of hospital Emergency Departments (ED)
- In first year, ED visits for the largest women’s shelter in Harris Co. was reduced by 72%
- Rate of STDs higher than in general female population
- STD education and testing offered to all women

## Conclusion

-     Patient satisfaction rate in the Women and Children’s Clinic is consistently the highest of all HHH programs
- 96% “satisfied or very satisfied” on all indicators
- Last year, one woman cried and told the
- clinician,“This is the first time I have ever been
- treated like a human by a doctor.”