The purpose of this Resource Guide is
to provide a greater understanding of
the clinical components of the Health
Care for the Homeless (HCH) Program,
section 330(h) of the Public Health
Service (PHS) Act. Ideally, this Resource
Guide may help both current and prospective
grantees funded under the HCH Program
better understand the delivery of services
to homeless individuals. This guidance
should be utilized as a companion document
to the Bureau of Primary Health Care
(BPHC) Policy Information Notice 98-23,
Health Center Program Expectations.
A. Program Goals
The goal of the HCH Program
is to improve the health status and
outcome of care for homeless individuals
and families by improving access to
primary health care and substance abuse
services. Access is improved through
outreach, case management, and linkages
to services such as mental health, housing,
benefits, and other critical supports.
Providers in HCH programs seek ways
to create new approaches to deliver
comprehensive care, unite providers
through collaboration, decrease fragmentation
of human services, and advocate on behalf
of homeless people.
B. Challenges
The BPHC recognizes that this
is an ambitious responsibility. The
challenges of the program are to:
Section 330 identifies the health
care and collateral services to be
provided to underserved and vulnerable
populations by all health center grant
recipients. For the purpose of this
Resource Guide, it is necessary to
define some terms in the context of
the HCH Program.
A. Case Management - Included
in the legislation in section 330(b)(1)(A)(iii)
as a required primary health service,
case management is defined as "apatient
case management services (including
counseling, referral, and follow-up
services) and other services designed
to assist health center patients in
establishing eligibility for and gaining
access to Federal, State, and local
programs that provide or financially
support the provision of medical,
social, educational, or other related
services." In the context of
the HCH Program, case management is
a practice modality which, in coordination
with the physical health/mental health/chemical
dependency treatment of the clients,
addresses the problems and needs associated
with the condition of homelessness.
Case managers coordinate support services
to meet the basic needs of an individual
by: 1) helping individuals obtain
safe, affordable, and permanent housing;
2) assuring access to treatment services;
3) providing crisis assistance; 4)
identifying educational and employment
options; and 5) developing a social
support network. Typical activities
of case managers can include accompanying
the client for appointments, consulting
with other care-givers, providing
counseling and advice, teaching living
skills, and advocating on behalf of
the client. Case management activities
are carried out within a context of
on-going assessment, care planning,
and monitoring.
While not necessarily needed or utilized
by every client, case management services
should be offered to those clients
who need them. Because problems and
needs vary from one homeless individual
to another, the scope, intensity and
process of providing services varies.
For example, the case management relationship
may be short-term or long-term in
duration, primary or ancillary in
role, intensive "hands-on"
or more advisory in approach. Effective
case managers are client-centered,
respectful, flexible, patient, collaborative
and creative in carrying out their
work. A case manager's professional
training may vary depending on program
design.
B. Complementary Treatment Modalities
- There is a growing body of evidence
that some alternative forms of health
care (e.g., massage, acupuncture,
chiropractic, homeopathy, etc.) have
been found to be beneficial in treating
the needs of some homeless individuals.
These alternative treatments may be
offered depending on the resources
and expertise of the individual
programs.
C. Dental Services - Section
330(b)(1)(A)(i) indicates that health
center programs should, at a minimum,
provide oral health assessment and
education. In addition to standard
preventive care such as assessment,
cleaning and education (which includes
pediatric dental screening), every
effort should be made to provide additional
corrective and emergency dental services.
If services are beyond the budgetary
scope of a program, every effort should
be made to develop referral resources
so that these services can be offered.
Where feasible, dental services should
not be limited to extractions but
should include restorations and prosthetics.
D. Enabling Services - Listed
in the statute in section 330(b)(1)(A)(iv)
as a required primary health service,
enabling services include outreach
(defined separately below), translation
services, and transportation. Transportation
assistance may be provided in a number
of ways such as bus passes and/or
taxi vouchers, or directly by the
grantee. It is critical that the absence
of transportation not become a barrier
to care. Enabling services also include
assistance in establishing eligibility
for and receiving benefits from public
entitlement programs including income
support, Medicare, Medicaid, Supplemental
Security Income, Veteran's Benefits,
and food stamps.
E. Homeless Individual -
A homeless individual is defined in
section 330(h)(4)(A) as "an individual
who lacks housing (without regard
to whether the individual is a member
of a family), including an individual
whose primary residence during the
night is a supervised public or private
facility (e.g., shelters) that provides
temporary living accommodations, and
an individual who is a resident in
transitional housing." 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
building or vehicle; or in any other
unstable or non-permanent situation.
An individual may be considered to
be homeless if that person is "doubled
up," 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. A recognition
of the instability of an individual's
living arrangements is critical to
the definition of homelessness.
F. Outreach - Outreach is
defined as an effort to approach and
engage homeless persons with the objective
of developing a relationship of trust.
Listed in section 330(b)(1)(A)(iv)
as an enabling service, outreach is
critical to the success of any HCH
program and is to be included as a
required service in all 330(h) programs.
For homeless programs, outreach takes
on a special importance due to the
alienation and estrangement of homeless
individuals, and should be performed
where homeless people are found, such
as shelters, the streets, parks, camps,
libraries, bus stations, and public
buildings. These relationships can
enable the outreach worker to offer
alternatives to the homeless individual's
current living situation; inform the
individual of the availability of
health care, substance abuse, mental
health, social service and other related
services; and assist him/her in accessing
needed services and provide ongoing
emotional support and follow-up. A
successful outreach program begins
by addressing an individual's immediate
survival needs, providing health education,
distributing some basic necessities
and supplies that contribute to health
promotion (e.g., hygiene items, condoms,
bleach, etc.), and establishing trusting
relationships. Programs are encouraged
to utilize outreach workers who are
the most appropriate and acceptable
to the people they serve. While an
outreach worker must certainly be
a person with integrity and professionalism,
that worker need not have a professional
degree and/or be licensed unless required
by the State. The outreach worker
should receive adequate training in
dealing with homeless persons and
be knowledgeable of local resources.
G. Screening - Section 330(b)(1)(A)
includes screening in the context
of preventive services (e.g., breast
and cervical cancer, elevated blood
lead levels, dental, etc.). In every
case where screening occurs, the provider
must make arrangements for follow-up
when problems are identified. When
a patient is diagnosed with a complex
condition such as cancer or HIV, adequate
treatment is often beyond the clinical
and budgetary scope of the HCH program.
In these instances, the patient should
be referred to the appropriate services
and provided assistance in accessing
these services. The patient's medical
record should reflect the referral.
H. Substance Abuse Services
- These services are defined in section
330(h)(4)(B) to include treatment
for abuse of alcohol or other drugs,
counseling, and other medical or psychosocial
treatment services. Typical components
of substance abuse services, often
provided through referral, may also
include screening and diagnosis, detoxification,
referrals for individual or group
counseling, self-help groups, alcohol
and drug education, residential recovery
programs, rehabilitation, remedial
education, vocational training services,
and alcohol/drug-free housing.
I. Transitional Housing -
Once a homeless person obtains housing,
he or she is often considered to be
in a transitional status for a considerable
period of time. It is not uncommon
for an individual who has been homeless
to obtain housing but, due to illness,
substance abuse, loss of employment
or other circumstances, subsequently
return to homelessness. Each HCH program
may set its own definition of transitional
housing based on available resources.
However, it is the intent of the HCH
program to continue services to formerly
homeless individuals for up to 12
months after the individual has obtained
housing.
A. Primary Health Care and
Substance Abuse Services
Section 330(h)(2) of the PHS Act requires
that HCH programs provide primary
health care and substance abuse services
to homeless individuals and families,
as well as to previously homeless
individuals while they are in transitional
housing. These services should include
a comprehensive program of preventive,
episodic, and ongoing care for acute
and chronic conditions. Services should
be provided within a case management
modality, as described in Section
II of this guidance. Substance abuse
services include treatment for alcohol
and/or drug abuse. The goal of substance
abuse services is to provide assistance
for homeless persons to abstain or
to decrease the negative consequences
of their use of substances. Grant
funds may be used for a variety of
treatment modalities in various settings,
including non-hospital and social
detoxification, residential treatment
such as halfway houses and social
model homes, and case management/counseling
support in the community.
B. Additional Services
Section 330(b)(2) defines additional
services as those "that are not
included as required primary health
services and that are appropriate
to meet the health needs of the population
served by the health center involved."
Programs should develop their own
array of services based on the needs
of their patients and available resources.
Mental health services are not a required
component under the HCH program. However,
arrangements for the delivery of mental
health services is a critical aspect
of a responsive service delivery system.
Diagnosis and treatment of these disorders
is often difficult due to the nature
of the illness itself, the conditions
associated with being homeless, and
a lack of critical support services.
In many cases, the diagnosis and treatment
of mental illness is complicated further
by the co-occurrence of substance
abuse disorders. Such dually-diagnosed
individuals are particularly vulnerable
to housing instability and homelessness.
Providing services for these individuals
presents a significant challenge for
HCH programs. For various reasons,
many of these individuals are not
served at all, or not very well, by
the mainstream mental health or substance
abuse treatment systems. Intervention
typically requires a patient, flexible,
and persistent approach over a lengthy
period of time. The HCH program, using
an interdisciplinary team approach
with linkages to other services, can
be effective in addressing the complex
problems and needs of these dually-diagnosed
individuals. To the extent that the
required services are not compromised,
HCH programs are strongly encouraged
to provide, or make arrangements for
clients to access, the following additional
services:
-
Adult vision and hearing screening
- Complementary
treatment modalities (see Section II)
-
Directly observed therapy
-
Employment/job training assistance
-
Housing assistance Nutrition counseling
-
Podiatry services
- Representative
payee services
-
Respite/convalescent services
-
Restorative dental services
-
Vision services and eyeglasses
A. Service Delivery Models
A variety of community-based organizations
sponsor HCH programs. Currently, nearly
half of the programs are sponsored by
federally-funded community and migrant
health centers; the remaining programs
are supported by public health departments,
hospitals, community coalitions, and other
community-based groups.
The diversity of needs among homeless
persons in various communities, and the
variety among local service delivery systems,
has spawned a diversity in service models.
Many HCH programs provide services in
stable clinic sites, whereas some programs
are strictly shelterbased. Other HCH programs
use mobile units of various types to take
health care services to locations where
homeless individuals are found, including
the streets, parks, and soup kitchens.
Many programs utilize a hybrid of several
types of service delivery models. Some
HCH programs utilize paid primary care
providers including physician assistants
and advanced practice nurses, while others
depend on a closely scheduled volunteer
staff to provide the bulk of the care.
Each individual HCH program is free to
determine which service delivery system
or combination of systems is appropriate
for the clients and geographic area it
serves. The appropriate model for a particular
program should be determined following
a thorough needs assessment. It should
also be carefully re-assessed whenever
environmental changes dictate, preferably
at least every 5 years, to assure that
the HCH program is meeting the needs of
the maximum number of people with as high
a degree of efficacy as possible.
B. Accessibility and Availability
In order to create optimal availability
and accessibility of services, programs
must overcome common obstacles homeless
people face in accessing health and social
services. Some approaches include:
-
establishing hours of service that are
convenient for homeless individuals
and families;
-
providing services in locations where
homeless people gather regularly;
-
taking services directly to homeless
people who are the most vulnerable and
least likely
to seek assistance;
-
minimizing language and cultural barriers
through use of culturally competent
staff;
-
providing transportation assistance
for follow-up appointments with HCH
or referral
agencies;
-
promoting awareness of available HCH
services in the community through direct
outreach to homeless people; and
-
building trust with homeless people
by treating them with dignity and respect.
C. Collaborative Partners
Programs that serve homeless individuals
are expected to establish collaborative
linkages with other programs which serve
homeless people in their communities.
These linkage partners should include
existing health care providers, local
social service agencies, shelter providers,
and other providers of housing services.
Programs should also actively participate
in, and provide leadership to, community
coalitions which address the needs of
vulnerable populations.
In addition to the various Department
of Health and Human Services programs
to assist homeless persons, HCH programs
should be aware of other programs within
the Federal Government that exist to help
homeless individuals. For example, there
are programs in the Departments of Housing
and Urban Development, Labor, and the
Veterans Administration which specifically
target homeless people. There are also
local and State government programs, as
well as those in the private sector, that
exist to aid homeless individuals. Programs
are strongly encouraged to apply for funding
from these other programs. Likewise, programs
are also encouraged to access resources
from programs that are not specifically
targeted at the needs of homeless people,
such as Medicaid, Maternal and Child Health,
Ryan White, and similar programs.
5. ADDITIONAL RESOURCES
Additional resources for current and prospective
grantees funded under the HCH Program
are available
through:
HCH Information Resource Center
Policy Research Associates, Inc.
262 Delaware Avenue
Delmar, NY 12054
Phone: Toll-free (888)439-3300, ext. 246
hch@prainc.com
Another excellent resource is Organizing
Health Services for Homeless People --
A Practical Guide, by
Marsha McMurray-Avila, which is available
through:
National Health Care for the Homeless
Council
P.O. Box 60427
Nashville, TN 37206-0427
(615)226-2292
hch@nashville.net
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