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 center’s 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


INTRODUCI’ION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1


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


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


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


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


Shelters Referring Clients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


OPPORTUNITmS FOR IMPROVEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . ...8


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


7 
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. 

Homeless People 

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-1960’s. Originally managed under the Economic 

Opportunity Act, the neighborhood health center program was transferred to the 

Public Health Service in the early 1970’s. 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 patient’s 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 CHC’S can best service the health care needs of 

homeless persons. 

SampleSelection 

We used the Bureau of Primary Health Care’s 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 President’s 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 

40 

34 

26 

19 

8 

Type of Services


Laboratory services


Prescription drugs


Radiology services


Mental health counseling


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 follow”ng 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 center’s 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 Care’s 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 HRSA’S and ASPE’S comments are attached. We appreciate their 

advice and assistance in this study. 

9

AGENCY COMMENTS 

10 
2 .“ DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health SeNice 2

,

5 

*+, 

>

-@o 4

J?V,, 

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 OIG’S 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 OIG’S consideration.


Attachment

DEPARTMENT OF HEALTH & HUMAN SERVICES Office of the Secretary 

Washington, D.C, 20201 

MAY i ~ 1996 

Jnw GibbsBrown 

Jnspector General 

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 opportunity toreview
the 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 referral of homeless clients. The reported barriers to services and 

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 that overtwo-thirds
 ofthe 

homeless dicnts treated were staying in an emergency shelter or livingwithjbnll’yor 

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 

shed some light m the types of scrvkwsto which sheItersreport making referrals, (and 

WIWKCEK2Srank in’relatkmship 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 eff’cotsof actions 

to adr.iressbarriers (c,g,, increased access to services, improved quality in screening, 

increased servioe usage, etc.). 

Xfthedata permit report onthedfierenee
 inthebtiers identified by CHCS and those 

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. 

(72-4,$j22 

Peter B. Edehnan