Slide 1:

Chronic Homelessness in the Rural Setting

Healthcare for the Homeless,
Yellowstone City-County
Health Department

Lori Hartford RN BSN
Program Manager HCH

Slide 2:

Healthcare for the Homeless

• History of HCH in Montana
• Current Services Available
• Characteristics of rural homelessness
• Barriers for homeless persons in accessing mainstream services
• Solutions to address barriers
• Community partnerships

Slide 3:

History of HCH in Montana

• Billings HCH first funded in 1992.
• Bureau of Primary Health Care funding 330(h)
• Yellowstone City-County Health Department also has a Community Health Center as well as other public health programs
• One of 154 HCH programs across the country, at least one in every state
• Expansions to 3 other towns in Montana since 1999

Slide 4:

Montana HCH Network

• Helena 1999
• Missoula 2000
• Butte 2001
• Sub-grantee agreements with Community Health Centers
• Network links towns on the major highway network in Montana

Slide 5:

Montana Geographic Comparison to Other States

This slide shows a map of the state of Montana superimposed on top of several other States to show a size comparison. The area it is superimposed on is:

• The lower portion of Michigan
• About half of Idaho
• The northeast corner of Illinois
• The southeast corner of Wisconsin
• The most nothern portion of Kentucky
• Almost all of Ohio
• A little more than half of Pennsylvania
• Western New York
• Northern West Virginia
• Western Maryland
• The tip of Northern Virginia
• Lake Erie
• Southern part of Lake Michigan

Slide 6:

Montana

• 45 of 56 counties are ‘frontier’
• 8 of 56 counties are rural
• 3 of 56 counties are urban
• Total population: 902,195 people
• Estimated homeless population: 11,000 individuals homeless at some point during each year

Slide 7:

Healthcare for the Homeless
What we do:

• Provide for primary health and dental care, and mental health/substance abuse services at locations accessible to homeless people
• Provide for emergency care with referrals to hospitals for in-patient care services and/or to needed mental health services; and
• Provide for case management and outreach services to access difficult to reach homeless persons, and for aid in establishing eligibility for entitlement programs and housing.

Slide 8:

Definition of homelessness for HCH Program

• “ A homeless person is an individual without permanent housing who may live on the streets; stay in a shelter, mission, single room occupancy facilities, abandoned buildings, or vehicles; or in any other unstable or non-permanent situation. An individual may also be considered to be homeless if that person is “doubled-up”.”

Slide 9:

Doubled-up

• Doubled-up is a term that refers to a situation where individuals are unable to maintain their housing situation and are forced to stay with a series of friends and/or extended family members.
• In addition, previously homeless individuals who are to be released from a prison or a hospital may be considered homeless if they do not have a stable housing situation to which they can return.

Slide 10:

KEY POINT

• RECOGNITION OF THE INSTABILITY OF AN INDIVIDUAL’S LIVING ARRANGEMENTS IS CRITICAL TO THE DEFINITION OF HOMELESS FOR THE PURPOSES OF THE HEALTHCARE FOR THE HOMELESS PROGRAM!

Slide 11:

Homeless vs. Montana
Demographics

HCH	Age	Montana
7%	<18 yrs	25.5%
11%	18-24 yrs	9.5%
46.6%	25-44 yrs	27.5%
34%	45-64 yrs	24%
2%	>65 yrs	13.5%

Slide 12:

Ethnic Demographics

HCH		Montana
0.3%	Asian	<0.1%
2%	Black	1%
11%	Amer. Indian	6%
82%	White	91%
2.5%	Hispanic	2%
2.5%	Refused to rpt	<0.1%

Slide 13:

Income and Insurance
Demographics

HCH		Montana
95%	<100% Poverty	14.6%
2%	101-150%	26%
0.6%	151-200%	37%
2%	>200%	22.4%
80%	No insurance	19%
12%	Medicaid	6%
6%	Medicare	15%
2%	Private Ins	60%

Slide 14:

Frequent Health Problems HCH vs. CHC population, UDS data

HCH n=1839		CHC n=9476
0.7%	HIV/AIDS	1%
13%	Respiratory	7%
7.5%	Diabetes	7%
13%	Hypertension	10%
5%	Ear Infections	5%
12%	Alcohol/Drugs	5%
30%	Mental Illness	22%
9%	Women’s Health	18%

Slide 15:

Healthcare for the Homeless

This slide has a picture of man on the street next to a building.

Slide 16:

HCH staffing pattern

• RN/LPN Case Manager (Human Service background)
• Medical Provider (FNP, PA-C or MD)
• Therapist (LCSW or LCPC)
• Substance Abuse Counselor (LAC)
• Outreach Staff
• Clerical Staff
• 24/7 Medical coverage available through CHC

Slide 17:

Billings HCH

This slide has two pictures of the Montana Rescue Mission on it.

Slide 18:

Volunteer Dental Program

• Started in 1995
• Community dentists volunteer time in either their offices or at the CHC Dental Office.
• 17 volunteers in Billings

Slide 19:

Medical Services

Picture of Bob Giusti, FNP assessing a homeless man for health problems at the Montana Rescue Mission in Billings.

Slide 20:

Outreach

This slide has a picture of a mobil outreach van on it. It also has a picture of the underside of a bridge.

Slide 21:

This slide has a picture of a Homeless Healthcare worker talking with a man and a child.

Slide 22:

Case Management Activities

This slide has a picture of a case manager talking with a street person outside St. Vincent de Paul Thrift store to follow-up on his Social Security application and housing.

Slide 23:

Deering Community Health Center/Family Practice Center

This slide has a picture of the entrance to the Deering Community Health Center/Family Practice Center.

Slide 24:

Expansion to other sites

• Development of a state wide network of Healthcare for the Homeless programs in Montana.
• Provision of HCH services in four unique rural communities, with outreach to others communities.
• Importance of involvement of local service providers in the planning for and provision of services.

Slide 25:

Helena HCH families make a quilt

This slide shows a picture of the quilt made by Helena HCH families.

• A dream of a new house by a homeless child at the God’s Love Shelter.
• We help build dreams for homeless families by helping them be healthy

Slide 26:

Quilt panel

This slide shows a panel in the quilt. The panel is of a rain storm in the mountains.

• Rain in the mountains, and in her life for a child.
• We offer hope to lift the clouds.

Slide 27:

The mountains outside of Helena

This slide shows a picture of the mountains outside of Helena

• Many homeless people live in and around the mountains outside of Helena.
• Montana natives are fiercely proud and independent.
• Many are reluctant to seek out “government welfare”

Slide 28:

A veteran seeks HCH care

• The HCH nurse coordinates care with local VA hospital
• She obtains medications for clients who are waiting for their VA medications in the mail.

Slide 29:

Missoula HCH ProgramPoverello Shelter outreach site

This slide shows a picture of the Missoula HCH Program Poverello Shelter outreach site.

Slide 30:

Care with Dignity

This slide shows a picture of a women reading to two children.

Slide 31:

Montana is a rural state with many areas that are considered frontier

This slide has two pictures of the Montana country side. One is of the mountains and one is of a farming area.

Slide 32:

Rural homeless people are often not readily visible and therefore underindentified.

This slide has a picture of the mountains in Montana on it.

Slide 33:

This slide has a picture of an animal in a field on it.

Slide 34:

Yes, there are people who are homeless in Montana!

This slide has a picture of a man on the street.

Slide 35:

Properties of rural homeless people. (RECD data, 1996)

• More apt to live in a shack without plumbing or heating; a car or camper
• Higher percent are doubled-up in substandard was well as overcrowded housing
• Homeless specific services rare in rural areas
• Disproportionately high numbers of mothers with children, veterans, and others who may not have a long history of homelessness
• Losing a home is directly connected with losing a job, very vulnerable to the uncertain rural economy
• Often in transition from one area to another

Slide 36:

Properties, con’t.

• Many women are fleeing an abusive relationship, not many DV shelters in rural areas.
• Migrant laborers who are searching for seasonal work and have exhausted their resources, leaving them stranded in a rural area.
• Many rural people feel so stigmatized by being homeless that they will not even use the word.
• Like in urban areas, homeless people experience a high percentage of mental illness, alcohol and drug dependence. These services are poor in rural areas and often do not even exist.

Slide 37:

Rural advantages

• In many small towns the word community still has meaning.
• Basic costs of living are lower than in urban areas.
• Community networks of support often exist, either formal or informal.
• “ There are fewer strangers in rural America”, “The smaller the town, the more willing everyone was to help”
  
  (Rural Economic and Community Development Report 1996)

Slide 38:

Barriers homeless people face to access mainstream services

• Summary data from the Building Partnerships for Access Conference in Washington DC, September 7-8, 2000.
• Systems, services and funding is fragmented (limited connectivity between agencies, ie no universal application, multiple locations to get basic needs met)
• Restrictive, excessive and cumbersome administrative procedures (documentation requirements, regulations that exclude substance abusers, convicts, forms very complex)

Slide 39:

Barriers

• Outreach for homeless people by mainstream programs is a low priority (very labor intensive in a cost-cutting environment, lack of funding)
• Homeless people stigmatized by providers and mainstream systems. (negative, sometimes hostile attitude towards homeless, mentally ill, substance abusers; staff resistance to serving homeless)

Slide 40:

Barriers

• Poorly prepared and insensitive staff (limited opportunities for staff training regarding homeless and cultural competency issues)
• System has insufficient capacity (most systems already at overcapacity, services not available where clients are)
• Clients mistrust the “system” (fears of traditional agencies: child custody loss, hygiene issues, lack of documentation, fear of the government, system not always client centered or friendly)

Slide 41:

Barriers

• Homeless people are a hard to reach population. (mobile population, need for transportation, especially in rural areas)
• Child care issues (most public agencies are not “kid-friendly” and parents don’t have access to safe daycare)
• Most mainstream agencies do not have the homeless people on their consumer advisory boards to get their input.

Slide 42:

Solutions - Prevention

Prevention is the key to alleviating rural homelessness:

• Affordable housing
• Living wage
• Active case management for those at risk of becoming homeless, through existing programs; i.e. Mental Health Centers (PATH programs), Human Resource Developments Councils, DFS, APS, etc.

Slide 43:

This slide has a picture of a residence on it.

Slide 44:

Solutions- Collaboration

• Community networking and collaborations to identify existing “local experts” and develop local solutions.
• Montana HCH programs each actively participate regularly with local coalitions of other social service agencies that deal in some way with homeless people. These coalitions were critical to develop the HCH programs, but more importantly offer a means for individuals within each of these agencies to become their own “in-house” experts to train others in their agency regarding homeless issues, sensitivities, and how to refer for services they don’t offer them selves.

Slide 45:

Collaboration

• Include homeless persons, who are representative of your local ethnic demographics in these coalitions, no one is more expert than those who are there, or who have been there!!
• Monthly or quarterly meetings of your coalition allow all agencies involved to keep abreast of new programs at each agency. Send minutes to those who are absent.
• Include Faith-based programs in your coalition, they have been serving the homeless in your community, often silently for years!
• Interfaith Hospitality Network.

Slide 46:

Homeless Veteran’s Stand Down

• 1,069 Veterans at Kalispell Stand Down 2002. Many living in the forests from Kalispell to Libby
• Billings Stand Down involves all agencies that offer services to homeless and low income.
• Provides ongoing support services all year.

Slide 47:

This slide has a picture of a women giving a man a shot at a Stand Down in 2001.

Slide 48:

Advocacy and Consumer Respect and Involvement

• Hire people who are, or have been homeless for positions they can qualify for within your agency, this will allow your local homeless people to have a welcome face that they can trust so that you can engage them for services.
• Advocate within your agency for the homeless, become a mentor to peers to increase their comfort level with homeless people.

Slide 49:

Consolidation and Integration

• One-stop shopping facilitates increased usage by homeless people.
• Montana Job Service Workforce Centers: an excellent model of programs that work.
• Modify eligibility applications to be as consistent as possible across agencies within your coalition. (Billings Homeless Board Computer network, uses the same enrollment form at local helping agencies, networked at one server to avoid unnecessary duplication of enrollment forms, and to increase access.)
• Assess your documentation requirements to see if these create barriers in your agency.

Slide 50:

Standardize and streamline inclusive service delivery

• One stop accessible locations for enrollment (out-stationing, co-location)
• Common eligibility regulations
• Simplify eligibility application process (telephone intakes)
• Intensive caseworkers to help clients navigate your system, or inter-agency outreach/case management contracts
• Mobility of benefits from county to county and state to state

Slide 51:

Maximizing funding flexibility and capacity

• Leveraging public funds to integrate programs (Ending Chronic Homeless Initiative: HUD/VA/SAMHSA/BPHC funding)
• Evaluate the use of local or state funds to match federal funds
• Evaluate if you have flexibility of TANF block grant funds to address the needs of homeless people

Slide 52:

Competency training for all levels of staff

• Training from the top down regarding the needs of your local homeless people
• Inter-agency training in cultural expertise and capacity for collaboration as well as networking
• Utilize your local experts for the cultural/ethnic specifics of your area
• Reward your staff for learning and practicing these culturally competent skills
• Utilize quantifiable evaluations of your staff, which includes cultural competency specific to your locale

Slide 53:

This slide has a picture of a sculpture of two men on horses.

Slide 54:

Partnerships

• Federal: Integrated federal funding for partnership projects
• State: Interagency task groups on services coordination
• Include homeless experts
• One stop homeless access
• Partner with foundations/funders to develop gap funding
• State level forums on homelessness, affordable housing and human services
• Communication between grassroots advocates and decision makers

Slide 55:

Partnerships (con’t)

• Local: Cooperative interagency referrals and data sharing
• Partnerships with faith organizations
• Interagency outreach and enrollment contracts
• Downtown business partnerships for outreach
• Community outreach
• Advertising partnerships (PSA, etc) to educate your community about homelessness
• Partner with local hospitals for discharge planning

Slide 56:

Partnerships (con’t)

• Partner with your local homeless shelters (if you have them) and other service agencies to provide on-site enrollment in Medicaid, housing assistance, etc.
• Collaborate with your local police departments, fire service, ambulance: They can be some of your best outreach workers!

Slide 57:

Partnerships (con’t)

• “NOTHING ABOUT ME, WITHOUT ME”
• Include your homeless and previously homeless population to get local/state needs assessments done regularly
• Utilize technical assistance that is available through the National Healthcare for the Homeless Clinician’s Network

Slide 58:

This slide has a picture overlooking a bay or lake and some hills beyond it.

Slide 59:

National Resources

• The National HCH Council and the HCH Clinician’s Network
  www.nhchc.org
• HCH Information Resource Center
  www.prainc.com/hch
• National Alliance to End Homelessness
  www.endhomelessness.org

Slide 60:

Lori Hartford, RN BSN
Yellowstone City-County Health Department
Healthcare for the Homeless
Program Manager
123 South 27th Street
Billings MT 59101
(406) 247-3358
lorih@ycchd.org