Department  of  Health  and  Human  Sewices 
OFFICE  OF 
INSPECTOR  GENERAL 
ACCESS  TO  COMMUNIW  HEALTH 
CENTERS  BY HOMELESS  PERSONS 
L 
.  EXECUTIVE  SUMMARY

PURPOSE 
To  determine  the  extent  that  Federally  funded  community  health  centers  serve 
homeless  people  and  how such services  can be improved. 
BACKGROUND 
This  survey was requested  by the  Office  of the  ksistant  Secretary  for Planning  and 
Evaluation,  (ASPE)  representing  the  Secretary  of the  Department  of Health  and 
Human  Services  as a member  of the  Federal  Interagency  Council  on the  Homeless. 
Community  health  centers  (CHCS)  are  health  clinics that  provide  comprehensive 
family-oriented  preventive  and  primary  health  semices  to medically  underserved, 
disadvantaged  populations  experiencing  financial,  geographic,  or  cultural  barriers  to 
care.  There  are  623 Federally  supported  centers  in the  U.S. and  its territories  which 
seine  over  seven  million  people. 
We  selected  a random  sample  of 72 urban  centers.  We  then  obtained  the  names  and 
addresses  of homeless  shelters  in each  of the  their  service  areas.  We  did not  gather 
information  from  centers  which received  grants  under  the  Health  Care  for the 
Homeless  Program  since  these  programs  are  funded  to serve  the  health  care  needs  of 
homeless  persons. 
We  mailed  surveys  to the  sample  of centers  and  homeless  shelters.  These  surveys 
focused  on barriers  on accessing  services,  outreach  services  to the  shelters,  referrals  of 
homeless  clients,  treatment  services,  and  case  management  for homeless  persons.  We 
received  surveys  from  50 centers  and  98 shelters  in 46 cities. 
We  also conducted  on-site  visits at 6 cities with 7 CHCS and  16 nearby  shelters.  At 
these  cities we interviewed  center  management  and  the  directors  of homeless  shelters 
to supplement  and  clari~  information  from  the  surveys. 
FINDINGS 
Two Thirds  of the  Community  Health  Centers  Provide  Outreach  Services  for 
Homeless  PeopIe 
We  found  that  64 percent  (32 of 50) of the  CHCS provide  outreach  services  for 
homeless  people.  These  services  include  sending  staff to homeless  shelters,  and/or 
contacting  homeless  shelters  to provide  information  on services  available.  However, 
we found  that  for  13 of these  centers  at least  one  nearby  shelter  reported  that  the 
centers  do not  send  staff  to their  shelter. 
i  It is possible  that  in 9 of the  18 cities where  centers  did not  provide  outreach  services

the  health  care  needs  of homeless  persons  might  be  served  because  a specific  Health

Care  for the  Homeless  Program,  funded  under  a Federal  Section  340 Public  Health

Service  grant,  exists in those  cities.  However,  the  remaining  nine  cities had  neither  a

Health  Care  for  the  Homeless  Program  nor  outreach  from  the  local  center.

Community  Health  Centers  Provide  A Wide  Range  Of Treatment  Services  To

Homeless  People

The  CHCS provide  a broad  range  of treatment  services  such as acute  medical

examinations  and  treatment,  screening  services  for tuberculosis,  hypertension,  sexually

transmitted  diseases,  and  preventive  semices  including  well child  care,  immunizations,

comprehensive  physicals,  prenatal  monitoring,  and  dental.  They  also provide

prescription  drugs,  laboratory,  and  radiology  services.

Nevertheless,  The  Cknters  Face  Significant  Barriers  In Providing  Services

Sixty-nine  percent  (34 of 49) of the  CHCS reported  that  barriers  existed  with  homeless

persons  obtaining  setices  from  the  center.  The  most  significant  barriers  are  the  lack

of available  transportation,  the  centers  hours  of operation,  the  clients

inability/unwillingness  to follow through  on a plan  of care,  unavailability  of necessary

services  in the  community,  and  the  transient  status  of homeless  persons.  Fourteen

percent  adapted  their  treatment  or screening  protocols  to meet  the  needs  of homeless

clients.

Some  Homeless  Shelters  Do  Not  Refer  clients  To Nearby  Health  Centers

Twenty-eight  percent  (27 of 97) of the  shelters  reported  they  did not  refer  clients  to

the  centers  for  health  care  services.  The  remaining  70 homeless  shelters  did.  Shelter

clients  used  public  transportation,  shelter  bus tokens,  or their  own transportation  to

travel  to the  centers.  Others  walked,  relied  on family and  friends,  or in some  cases

used  an ambulance.

OPPORTCJMHES  FOR  IMPROVEMENT

The  findings  in this report  reflect  a greater  potential  for Community  Health  Centers

helping  homeless  people  and  suggest  that  better  communication  between  the  Health

Resources  and  Services  Administration  (HRSA)  and  the  centers,  and  between  the

centers  and  homeless  shelters  could  have  a positive  impact  on access  to medical

services  for homeless  individuals.

HRSA  can  pursue  improvements  in semices  offered  homeless  people  in the

Community  Health  Center  program  by building  on its existing  efforts.

This might  include:

  Developing  and  disseminating  materials  about  effective  practices. 
ii  .  Holding  workshops  and  training  sessions  for community  health  centers. 
.	 Emphasizing  the  responsibility  to lessen  all barriers  which  diminish  the  ability 
to serve  homeless  persons  who present  themselves  to the  clinic 
(e.g.,  hours  of operation,  transportation  to the  center). 
	 Encouraging  periodic  contact  between  management  of the  health  centers  and 
the  shelters. 
Community  Health  Centers  themselves  should  improve  communication  with  homeless 
shelters.  Some  ways to  accomplish  this include: 
	 Identifying  all homeless  shelters  that  exist in their  service  areas.  The  city task 
forces,  coalitions,  or networks  on hopelessness  are  valuable  resources. 
.	 Providing,  on a routine  basis,  information  to those  homeless  shelters  in their 
service  areas  on services  available  and  locations. 
.	 Conducting  periodic  meetings  with homeless  shelters  to discuss  the  medical 
needs  situation  in their  area,  the  barriers  that  exist, and  means  to best  address 
those  barriers. 
AGENCY  COMMENTS  AND  OIG  RESPONSE 
We  received  written  comments  from  both  HRSA  and  ASPE.  HRSA  concurred  with 
our  suggestions  and will develop  an action  plan  to implement  them.  ASPE 
commented  on the  importance  of the  findings, but  raised  some  questions  and  made 
recommendations  for  additional  analyses.  As they requested,  we clarified  our  use  of 
the  terms  homeless  and  outreach.  Their  suggestions  for additional  analysis  of such 
topics  as referral  patterns,  service  coordination,  emergency  services,  case  management, 
and  actions  taken  to address  barriers  are  important.  Unfortunately  they  are  beyond 
the  scope  of our  study, which was limited  primarily  to ascertaining  whether  and  to 
what  extent  the  community  health  centers  funded  by the  Federal  Government  were 
actively  involved  in serving  homeless  individuals.  Copies  of their  comments  are 
attached. 
... 
m  TABLE  OF  CONTENTS

PAGE

EXECUTIVE  SUMMARY

INTRODUCIION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4

Outreachservices  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4

Treatment  Services  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5

Barriers  to Services  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...6

Shelters  Referring  Clients  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
 7 
OPPORTUNITmS  FOR  IMPROVEMENT  . . . . . . . . . . . . . . . . . . . . . . . . . . . ...8

AGENCY  COMMENTS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...10
 INTRODUCTION

PURPOSE 
To  determine  the  extent  that  Federally  funded  community  health  centers  (CHCS) 
serve  homeless  people  and  how such selvices  can be  improved. 
BACKGROUND 
This  survey was requested  by the  Office  of the  Assistant  Secretary  for Planning  and 
Evaluation,  (ASPE)  representing  the  Secretary  of the  Department  of Health  and 
Human  Services  as a member  of The  Federal  Interagency  Task  Force  on the 
Homeless. 
HomelessPeople 
Homeless  people  are  a heterogeneous  group  of men,  women  and  children.  They 
include  long  term  street  dwellers,  residents  of homeless  shelters  and  temporary  living 
quarters,  the  chronically  mentally  ill, the  economically  disadvantaged,  single  men  and 
women,  the  physically  abused,  families  with children,  as well as runaway  and  castoff 
youths. 
Homeless  individuals  have  a variety  of health  care  problems,  including  a high 
incidence  of mental  illness  and  substance  abuse/alcohol  disorders.  In over  half  of the 
cases,  they  are  without  health  insurance  to cover  medical  care  for  physical  and 
emotional  problems. 
CommunityHealth Centem 
CHCS are  health  clinics that  were  first funded  by the  federal  government  as part  of 
the  War on Poverty  in the  mid-1960s.  Originally  managed  under  the  Economic 
Opportunity  Act,  the  neighborhood  health  center  program  was transferred  to the 
Public  Health  Service  in the  early  1970s.  Centers  are  located  in each  of the  50 States, 
the  District  of Columbia,  and  the  U.S. Territories  and  Possessions.  The  authorizing 
legislation  is Section  330 of the  Public  Health  Semite  Act,  Public  Law  94-63. 
The  centers  provide  comprehensive  family-oriented  preventive  and  primary  health 
services  to medically  undersexed,  disadvantaged  populations  experiencing  financial, 
geographic  or  cultural  barriers  to care.  They  tailor  services  to meet  the  specific  needs 
of the  community  and  special  populations  that  include  homeless  persons,  people 
infected  with  HIV/AIDS,  the  elderly,  and  substance  abusers. 
There  are  623 Federally  supported  CHCS in the  United  States  and  its territories. 
Serving  over  seven  million  people,  they are  a significant  component  of the  health  care 
services  industry  in this country.  An estimated  61 percent  of center  users  are 
1

..  members  of minority  groups  (27 percent  African  American,  27 percent  Hispanic,  and 
7 percent  other).  Also,  about  63 percent  have  incomes  under  the  poverty  level  and 
another  22 percent  are  between  100 and  200 percent  of poverty. 
To  fulfill the  provisions  of the  Public  Health  Service  Act  (42 USC  254c), the  centers 
must,  either  through  its staff  and  supporting  resources,  or through  contracts  or 
cooperative  arrangements: 
  Serve  areas  designated  as medically  underserved; 
	 Provide  basic  primary  medical  care  services  plus  support  and  facilitating 
semices  appropriate  for the  target  population; 
.	 Have  a governing  board  where  the  majority  of the  members  are  users  of the 
centers  sexvices; and 
  Adjust  the  cost  of services  to the  patients  ability  to pay. 
The  support  services  that  supplement  basic  services  include  mental  health  semices, 
dental  services,  eye examinations  and  glasses,  podiatry  services,  ambulatory  surgical 
services,  health  education  services  (including  nutrition  education),  and  other  services 
appropriate  to meet  the  health  needs  of their  medically  undersexed  population. 
Medical  services  are  provided  to homeless  individuals  who  present  themselves  to the 
center  for care.  Charges  for services  are  based  upon  income  of the  patient.  As such, 
homeless  individuals  are  served  as are  other  patients  who utilize  the  center  for 
medical  care. 
Correspondingly,  Health  Care  for  the  Homeless  Programs  (Section  340 of the  Act), 
which were  not  the  subject  of this study, receive  targeted  funds  and  thus  should  be 
more  able  to conduct  outreach  and  deal  with the  complex  problems  of individuals 
living on the  streets  and  in other  nontraditional  settings. 
METHODOIX)GY 
InspectionFocus 
The  inspection  focuses  on how CHCS can best  service  the  health  care  needs  of 
homeless  persons. 
SampleSelection 
We  used  the  Bureau  of Primary  Health  Cares  1994 Directory  of Prima~  Care 
Programs  to identify  centers  which were  funded  under  Section  330 of the  Public 
Health  Semite  Act.  We  excluded  any centers  which  also  received  special  funding  to 
operate  a Health  Care  for the  Homeless  Program. 
2  We  selected  from  the  universe  of 198 urban  Section  330 CHCS a random  sample  of

72 centers.  We  excluded  rural  centers  because  arandom  telephone  su~eyof30  rural

centers  had  shown  the  majority  of themdo  not  serve  on-the-street  homeless  persons

or do not  have  homeless  shelters  in their  service  areas.  From  the  sampled  centers  we

obtained  the  names  and  addresses  of 172 homeless  shelters  in their  service  areas.  In

addition  to a mail  survey sent  to sampled  centers  we conducted  on-site  visits to 6 cities

with  7 centers  and  16 shelters.  At these  cities we interviewed  the  centers

management  and  the  directors  of homeless  shelters  to supplement  and  clari~

information  from  the  surveys.

We mailed  surveys  to the  sample  of centers  and homeless  shelters.  These  surveys

focused  on the  following  issues with  data  pertaining  to calendar  year  1994.

  Outreach  semices  to the  shelters

  Treatment  services

  Barriers  on accessing  setices

  Referrals  of homeless  clients

We  received  completed  surveys from  50 centers  and  98 shelters  located  in 46 cities. 
Eighty-six  percent  of the  them  had  a corresponding  shelter  return  a sumey.  While  the 
surveys were  comprised  of many  closed-ended  questions,  we also  used  open-ended 
questions  which  provided  more  in-depth  information  to explain  and  expand  upon 
close-ended  responses. 
We  summarized  and  tabulated  the  self reported  responses  to all the  sumey  questions. 
The  responses  were  quantified  to determine  such issues  as the  extent  of barriers  that 
prevented  access  to services,  the  number  of CHCS that  provide  outreach  services  to 
homeless  shelters,  and  the  quantity  and  type  of referrals  for medical  and/or  financial 
services. 
Due  to sumey  constraints  in our  study design  we did not  examine  all health  center 
service  configurations  that  provide  medical  care  to homeless  people.  Therefore,  the 
total  extent  of arrangements  among  shelters  and  service  providers  to refer  to a 
particular  program  because  of specific  capabilities  could  not  be  taken  into  account. 
This  could  have  been  the  case  for  cities in our  study which  had  Health  Care  for the 
Homeless  Programs,  plus  an unknown  number  of those  cities where  other  programs 
may  also  serve  homeless  individuals. 
This  report  is one  of two related  reports  on health  care  for homeless  persons.  A 
companion  report  will address  the  extent  that  community  mental  health  centers  serve 
the  homeless  population. 
We  conducted  our  review  in accordance  with the  Quality Standardsfor Impectiorz.s 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
3
 FINDINGS

TWO THIRDS OF THE COMMUWTYHWTU  CENTERS PROVIDE 
OUTREACH SERKiTCESFOR HOMELESS PEOPLE 
Sixty-four  percent  (32 of 50) of the  centers  provide  outreach  semices  for  homeless 
persons.  These  centers  sent  staff to homeless  shelters,  soup  kitchens,  and  food 
pantries.  They  provided  information  on services  available  to homeless  clients,  assessed 
needs,  provided  food  and  clothing,  performed  medical  services,  screenings  and  triage. 
They  send  staff to the  majority  but  not  all of the  shelters  in their  service  areas. 
However,  we found  that  for  13 of them,  at least  one  nearby  homeless  shelter  reported 
that  the  center  did not  send  staff to their  shelter.  Also, in our  sample  of 50 centers 
we found  48 percent  (22 of the  46 cities)  have  Health  Care  for the  Homeless 
programs  funded  by a Federal  Section  340 grant.  This would  mean  that  such  a 
grantee  also operated  in the  city.  We  are  not,  however,  aware  of the  proximity  of 
those  grantees  to all the  homeless  shelters. 
The  remaining  centers  do not  contact  or send  staff to homeless  shelters  to  conduct 
outreach.  It is possible  that  in 9 of these  18 cities the  health  care  needs  of homeless 
people  might  be  served  because  a Health  Care  for the  Homeless  grantee  program 
exists in those  cities.  However,  the  remaining  nine  cities had  neither  a grantee  nor 
received  outreach  from  the  local  CHC. 
Shelter  staff identified  their  outreach  needs.  Following  are  examples  of some  of the 
outreach  services  which  they feel would be important. 
We are  always struggling  to help  our  residents  receive  needed  health  care. 
We would  welcome  contact  from  any medical  group  that  can  help, 
Not enough  clients  are  seen  due  to lack  of available  physicians  time.  There 
needs  to be  more  medication,  casework,  aftercare,  and  outreach  to  psychiatric 
patients, 
Non-emergency  transportation  should  be  accessible  to shelters  for  early 
morning  pick-up  for sick children  to get to the  clinic, 
They only visit our  shelter  every other  week.  A lot of times  clients  have  come 
and  gone  by the  time  they make  another  visit, 
We need  better  communication  specifically  about  services  they  offer  and  fees 
required.  Evening  and  Saturday  hours  would  be  helpful  for  the working 
families  who need  their  services. 
4
 COMMUNITY HEALTH  CENZZRS PROK71)EA  WIDE RANGE  OF 
TUE4131ENT SERWCES  TO HOMELESS PEOPLE 
The  centers  provide  a broad  range  of treatment  services.  The  type  of services  most 
commonly  provided  to homeless  clients  include: 
	 Acute  medical  examinations  and  treatment,  e.g. scabies,  lacerations,  and  foot 
ulcers. 
.	 Screening  services  for tuberculosis,  hypertension,  sexually  transmitted  diseases, 
and  human  immunodeficiency  virus. 
	 Preventive  services  including  well child care  (Early,  Periodic  Screening 
Development  and  Treatment  program),  immunizations  (adults  and  children), 
comprehensive  physicals,  prenatal  monitoring,  and  dental. 
As shown below,  a significant  number  of CHCS also provide  other  services  which  are 
available  to any homeless  patient. 
Number  of CHCS  Type  of Services

40  Laboratory  services

34  Prescription  drugs

26  Radiology  services

19  Mental  health  counseling

8  Substance  abuse  treatment

Thirty-one  of them  reported  the  percent  of treatments  that  were  associated  with 
emergencies.  The  responses  ranged  from  1 to 90 percent,  with  an  overall  average  of 
15 percent  of treatments  being  related  to emergencies. 
The  typical  center  in our  sample  operated  with  a budget  of $4.4 million,  treating  an 
average  of almost  15,000 persons/users  annually.  There  was an  average  of 264 
homeless  clients  served  out  of an estimated  500 homeless  persons  in their  service  area. 
Approximately  3 percent  of their  annual  budget  goes  toward  the  operating  costs for 
serving  homeless  clients.  In addition,  for those  centers  who reported  both  the  total 
number  of persons  served  and  the  total  homeless  clients  served,  approximately  two 
percent  of the  total  were  homeless. 
All centers  receive  funding  from  Federal  grants,  with  supporting  funds  from  State  and 
local  grants.  One-third  (34 percent)  also rely on foundations  and  donations.  Other 
sources  of revenue  include  third  party  payers,  like Medicare,  Medicaid,  and  patient 
payments.  Some  conduct  fund-raising  and  United  Way campaigns  as well. 
Fifty-eight  percent  of the  CHCS clients  are  single adults  over  age  20, with  over  half  of 
them  having  no insurance. 
5  The  centers  reported  that  at the  time  of their  first encounter,  homeless  clients  were 
living in the  followng locations  (in descending  order):  emergency  shelters, 
family/friends,  motels,  and  on the  street. 
NEYERZ?YELESS,ZWE CENTERSFACE SIGNIFICANT BARRIEIW IN 
PROWDING  SERWCES 
While  most  centers  provide  services  for homeless  persons,  nevertheless,  the  centers 
have  reported  significant  barriers  in reaching  them.  A number  of centers  were  not 
able  to report  how many  homeless  persons  they serve.  However,  the  figures  we do 
have  document  that  centers  are  not  reaching  all of the  homeless  population  in their 
service  area. 
Sixty-nine  percent  (34 of 49) of the  centers  reported  that  barriers  exist for homeless 
people  in obtaining  services.  The  most  significant  barriers  (in priority  order  as 
reported  by CHCS)  are: 
(1) The  lack  of available  transportation

(2) The  centers  hours  of operation

(3) Transient  status  of homeless  individuals  makes  it difficult  to establish  a plan

of care  (e.g.,  outreach,  transportation) 
(4) Clients  inability/unwillingness  to follow through  on a plan  of care 
(5) Other  necessary  services  not  available  in the  community  (e.g., affordable 
housing,  mental  health  services) 
In general,  the  shelter  responses  to barriers  paralleled  this list.  Additional  barriers 
reported  by the  shelters  include  the  clients unwillingness  to go to the  center  for 
sefices  and  the  client  not  staying  long enough  in the  shelter. 
Many  centers  indicated  that  they  attempt  to address  barriers  in making  services  more 
accessible  to homeless  clients.  The  following number  reported  specific  semices  or 
procedures  implemented  to address  barriers. 
Number  of CHCS  Actions  to Address  Barriers 
22  Provide  transportation  to the  center 
20  Changed  their  hours  and/or  extended  the  hours  of 
operation 
19  Improved  availability  of telephones 
8  Provide  services  at alternate  sites  (e.g. an  off-site  clinic) 
Fourteen  percent  (6 of 44) of the  centers  adapted  their  treatment  or screening 
protocols  to meet  the  needs  of homeless  clients.  Some  of these  efforts  include: 
.  Addressing  as many  health  needs  as possible  at the  initial  appointment, 
6
 	 Adjusting  any follow-up  plan  to consider  how the  needs  of homeless  clients  will 
impact  treatment  or follow-up. 
SOME HOMELESS SHELTERSDO NOT REFER CLIEN73  TO 
NEARBY CENTERS 
Twenty-eight  percent  (27 of 97) of the  homeless  shelters  reported  they  did not  refer 
clients  to centers  for  health  care  services.  Reasons  reported  (in priority  order) 
include: 
(1)  They  were  not  aware  of the  center

(2)  They  use  an existing  Health  Care  for the  Homeless  program

(3)  Clients  will not  access  a center  due  to long waits  for  appointments

(4)  The  center  is in a different  area  of town

(5)  Clients  will not  go there  due  to safety  concerns

(6)  The  center  is not  a member  of the  local  homeless  coalition

(7)  Centers  have  not  been  receptive  to homeless  individuals

The  remaining  homeless  shelters  referred  their  clients  to centers.  Shelter  clients  used 
public  transportation,  shelter  bus  tokens,  or their  own transportation  to  travel  to the 
center.  Others  walked,  relied  on family and  friends,  or in some  cases  used  an 
ambulance.  OPPORTUNITIES  FOR  IMPROVEMENT

The  findings  in this report  reflect  a greater  potential  for  CHCS helping  homeless 
people.  Better  communication  between  the  Health  Resources  and  Services 
Administration  (HRSA)  and  the  centers,  and  between  the  centers  and  homeless 
shelters  could  improve  access  to medical  semices  for homeless  individuals.  Therefore, 
we suggest  that: 
HW  SHOUW  PURSUE WPROJZUEN7X  IN SERIL?CESOFFERED HOMELESS 
PEOPLE IN THE COM~N~HEALIZ?  CENTER PROGRAM BYBUILZXNG  ON 
ITS EXXSTINGEFFORZS.  Examples  include: 
.	 Developing  and  disseminating  materials  which  outline  best practices  from  the 
Community  Health  Center  program  and,  as applicable,  the  Health  Care  for  the 
Homeless  Program  to improve  outreach  and  referral  techniques  to serve 
homeless  persons. 
.	 Holding  workshops  and  training  sessions  for Community  Health  Centers  as part 
of the  Bureau  of Primary  Health  Cares  program  presentations. 
HRSA SHOULD PROMOTE JZi59ESPR&4DCOLLABORATION BETWEEN  CHC% 
AVl)  N-Y  SHELTERS. 
HRSA  could  do this by such  activities  as: 
	 Emphasizing  the  responsibility  of CHCS to lessen  all barriers  which  diminish  the 
ability  to serve  homeless  persons  who present  themselves  to the  clinic 
(e.g., hours  of operation,  transportation  to the  center). 
	 Encouraging  periodic  contact  between  management  of the  center  and  shelters 
to assess  the  homeless  populations  medical  needs,  and  possible  solutions  to 
addressing  those  needs. 
	 Ensuring  that  national  associations  representing  homeless  shelters  are  provided 
listings  of CHCS nationally.  This will permit  these  organizations  to further 
disseminate  the  information  to local  homeless  shelters. 
CHC$ SHOULD lMPROVE COMMU..IGXTION  J??ITHHOMELESS  SHELTERS. 
Some  ways to accomplish  this include: 
	 Identifying  all homeless  shelters  that  exist in their  service  areas.  The  city task 
forces,  coalitions,  or networks  on homeless  populations  are  valuable  resources. 
	 Providing,  on a routine  basis,  information  to those  homeless  shelters  in their 
service  areas  on services  available  and  locations. 
8  	 Conducting  periodic  meetings  with homeless  shelters  to discuss  the  medical 
needs  situation  in their  area,  the  barriers  that  exist, and  means  to best  address 
those  barriers. 
AGENCY  COMMENTS  AND  OIG  RESPONSE 
We  received  written  comments  from  both  HRSA  and  ASPE.  HRSA  concurred  with 
our  suggestions  and  will develop  an action  plan  to implement  them.  ASPE 
commented  on the  importance  of the  findings, but  raised  some  questions  and  made 
recommendations  for additional  analyses. 
One  of ASPES  questions  relates  to the  definition  of homeless.  We  found  no 
uniform  or standard  definition  of this term.  For  example,  some  include  those 
individuals  who  reside  in transitional  housing  while others  do not.  Similarly,  some 
would  include  those  who  are  temporarily  staying with friends  or relatives  but  who 
otherwise  would  be  homeless,  while  others  would  not  consider  such  individuals  as 
homeless.  In preparing  our  survey we consulted  with staff  of both  HRSA  and  ASPE 
and  agreed  to gather  information  using a broad  definition.  We  explicitly  asked  the 
Community  Health  Centers  to identify  the  conditions  under  which  their  homeless 
clients  lived, including  those  temporarily  staying with  friends  and  relatives.  We 
modified  our  report  to make  this clear  and  have  provided  staff of HRSA  and  ASPE 
with  a summary  of responses  which we received  from  the  centers  on this matter. 
Similarly,  ASPE  requested  us to include  a definition  of outreach  and  the  types  of 
activities  it includes.  We  modified  our report  to provide  a fuller  description  of the 
kinds  of outreach  activities  provided  by the  centers  and  needed  by the  shelters. 
ASPE  requested  analysis  of additional  topics,  such as referral  patterns,  service 
coordination,  emergency  services,  case management,  and  actions  taken  to  address 
barriers.  We  agree  that  these  are  all very important  topics.  Unfortunately  they  are 
beyond  the  scope  of our  study.  In our  early  consultations  with both  ASPE  and  HRSA 
staff we agreed  that  our  review would  be  limited  primarily  to ascertaining  whether  and 
to what  extent  the  community  health  centers  funded  by the  Federal  Government  were 
actively  involved  in serving  homeless  individuals.  We  also expected  to identify  issues 
for further  study,  such  as those  described  by ASPE  in their  comments.  Nevertheless, 
even  though  we did not  gather  extensive  data  on the  these  subjects,  our  staff  are 
available  to provide  insights  on these  or other  such topics  based  on their  observations 
and  impressions  from  their  site visits. 
The  full text  of HRSAS and  ASPES comments  are  attached.  We  appreciate  their 
advice  and  assistance  in this study. 
9
 AGENCY  COMMENTS 
10  22.   -@ DEPARTMENT OF HEALTH & HUMAN SERVICES 
Public  Health  SeNice
,
5 
*+, 
4
J>?Vo,, 
Health  Resources  and 
Services  Administration 
Rockville  MD  20857 
~/$(  8  l~!% 
TO:  Inspector  General, OS, DHHS

FROM:  Deputy Administrator

SUBJECT :	 Office  of Inspector General  (OIG) Draft Report  Access

to Community Health Centers by the Homeless

OEI-07-95-00060

This is in response  to your March 22, 1996, memorandum  requesting

comments to the draft report,  Access to Community  Health  Centers

by the Homeless.   We concur with the OIGS suggestions  that HRSA

should: 1) pursue  improvements  in services offered  homeless

people in the Community Health Center  (CHC) program  by building

on existing efforts,  2) promote widespread  collaboration  between

CHCS and nearby  shelters, and 3) determine how CHCS  should

improve communication  with homeless shelters.  HRSA  will  develop

an action plan,  including  target dates, to implement  the

suggestions and will take into consideration  the examples  the OIG

offered concerning  their implementation.

Additionally,  attached  is a marked-up copy of the draft  report

with editorial  and margin  comments for the OIGS consideration.

Attachment
 DEPARTMENT  OF HEALTH  & HUMAN  SERVICES  Office of the  Secretary 
Washington,  D.C,  20201 
1996 
MAY  i ~ 
Jnw GibbsBrown 
JnspectorGeneral 
FROM:  Assistant Secretary for Planning and Evaluation 
SU3JECT:	 Comments on the OIG Dmft Repofi Access to Community Health Centers by 
the Homeless/ OE1-07-95-00060 
Thank you very much for the opportuntiotrye vietwh
e above referenwd draft, Knowledge
about the extent that Federally funded wmununity health centers (CHCS)serve the homeless and 
how such serviees can be improved is highly important  In general, we found the report 
comprehensive: it addressed outreach services to shelters, treatment sewices, barriers to 
acwssing services and the  of homeless clients.  The reported barriers to services and 
referral 
reasons given by shelters for not refcrrkg clients to centers for health care services is importanl. 
We did, however, have some conwns  and recommendations. 
1,  Definitions:  Absent were definitions of homeIess and outreaeh. Without the deflnhions, 
the findings beoome obfuscated. For example, the report states thaotv ertwo-thirodftsh
 e 
homeless dicnts treated were staying in an emergency shelter or livingwithjbnllyor 
jWm?s. We had not included the latter group in our definition ofhomcless--did the 
CHC!awrite this in as an other category? The definition of homeless is of critical 
importance, particularly, as it is used as part of the rationale for excluding rural centers 
(i.e., the majority of rural centers do not serve the normal on-th~street homeless.) We 
are not sure of what is mewt by normal we surmise that tho report is referring to 
persons who are lilendly homeless. 
The finding that some centers did not send staff to shelters omdd be better interpreted if 
there was a definition of outreach serviees and the types of activities it included, As it 
reads now, outreach includes providing Mormation on available services, visiting 
shelters, having contact with homeless people, non-emergency transportation,  and hours 
of serviee. 
2.	 Exc!usion  of rural centers.  With regard to the probe which led to the exclusion of rural 
centers, more information about tlw probo is needed to add clarity and justification for 
their cxclusioll  How was the probe conducted? Did it consist of site visits endor 
convemations with key informants?  We recwnrncnd you provide more htiormation on 
tile probe used to exclude rural centers.  Page 2- June Gibbs Brown 
30	 Referrals.  The reports cites constraints on the survey design as the reason for not being 
able to take into account the total extent of referral patterns. If there any data that wuId 
shedsome lightm thetypes ofscrvkwstowhich sheItersreportmaking referrals, (and 
WIWKCEK2Srank inrelatkmship to otbortypes of m-vices ) please provide them, 
4.	 Service coordination.  Mentioned in a couple of places is the m-location of HeaIth Care 
for the Homeless (HCH) programs in the same community,  If these ciatapermi$  please 
report on referral activities and other service coordbation activities in places where HCH 
pro~ams  w  eo-lo~ted. 
5.  Emergency  services and ease management.  An interesting finding is the reported 
percentage of emergency scrviecs provided to homeless clients,  A related quesdon is 
whether these were in fact true emergencies or were persons aoccssing primary health 
care through the emergeney room.  If data m  available on the nature of the 
emergencies, we request that they be reported. 
Additionally, did any of the centers report providing ease management services? If so, 
report the percentage which provide case management servieea. 
6,	 Barriers.  Important f-s  were presented on the actions taken to address the barriers 
to servioe, A fh,hly common reported action was the itnpmved availability of 
telephones.  Please clari& what is meant by the action (e,g., were 1-800 numbers or hot 
Iincs added or were telephones made available within the oommunit.its)? 
If the data permit, pIease report comments made by respondents on the effcotsof  actions 
to adr.iressbarriers (c,g,, increased access to services, improved quality in screening, 
increased servioe usage, etc.). 
Xfthedata permit  reporotn thedfierenienet
 hebtiers  identified by CHCS andthose 
identified by shekms? 
-7.	 People focused  kmguage (rather than illness and homeless focused), The report 
consisted  y refers to homeless persons as the homeless and persons with chronic 
mcnlal illness as Ihe chronieajly rncmkdlyill, We mornmend  you revise the 
terminologies to read: homeIcss persons or homeless peopl% and persons with chronic 
mental ihess. 
We hope the comments and recomrnendatiom will be usefid and look forward to receiving the 
fma!report. 
(7
2-4,$j22 
Peter B. Edehnan