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NCBI Bookshelf. Homelessness, Health, and Human Needs. To the extent that homeless people have been able to obtain needed health care services, they have relied on emergency rooms, clinics, hospitals, and other facilities that serve Homeless man seeks help poor. Indigent people with or without a home experience many obstacles in obtaining health care. For homeless people there are additional barriers. Recognition of the special health care needs of homeless people has encouraged the development of special services for them.
In observing and describing these health care and health care-related services, one must be mindful of the heterogeneous nature of the homeless population, as well as the structure of the communities in which such services have developed. Regardless of differences among homeless people or regional variations in services, however, homeless people are more susceptible to certain diseases, have greater difficulty getting health care, and are harder to treat than other people, all because they lack a home.
Similarly, attempts to provide health and mental health care services, regardless of variations in such areas as history, funding levels, and nature of support, also have certain common elements. They arose in response to a crisis rather than developing as part of a well thought out plan. They generally brought services to homeless people rather than waiting for them to come in; increasingly, they rely on public funding because the problem has grown beyond a level that the private sector can support.
The purpose of this chapter is to describe programs that seek to bring general health and mental health care services to homeless people. The information presented in this chapter is largely based on the 11 site visits made by members of the study committee and its staff.
Although the sites are not representative of the entire universe of programs for the homeless, they were selected to include the broadest range of programs possible and to be geographically dispersed throughout the country. In studying health care and related services for homeless people, the committee sought to examine a broad range of services developed over a period of time, rather than to focus only on specialized services or services that have been developed recently.
However, what the committee observed were discrete services and programs. At no time did the committee encounter anything that could be appropriately called a ''system" of services. Before describing how these various programs bring general health care and mental health care to the homeless, we must address two major issues: 1 what makes serving the homeless, in contrast to the indigent in general, more difficult?
In Chapter 3we discussed those aspects of treatment that are especially difficult to implement when the patient is homeless. However, one must also look at the people who are homeless. William Breakey in press has identified characteristics of homeless people that affect the provision of treatment and the planning of health care services:. Daily Activities —Some homeless people live under circumstances that pose particular problems for developing a treatment plan. For many, it may be difficult to keep a supply of medication while living on the street. For an alcoholic trying to stay sober, a homeless existence may present too many opportunities for drinking.
Some former patients Homeless man seeks help that neuroleptic medications, prescribed for a schizophrenic illness, may make them too drowsy and interfere with their alertness against the dangers on the streets. Multiplicity of Needs —In addition to physical and mental health problems and difficulties with such things as housing and income maintenance, homeless people often also suffer from drug or alcohol abuse.
Any health care program for homeless adults should expect that 25 to 40 percent of patients will suffer from serious alcohol or drug abuse problems Fischer and Breakey, Disaffiliation —Although many homeless people establish individual support networks outside a family structure, some homeless people typically lack those networks that enable most people to sustain themselves in society.
Such isolation often causes and sometimes is caused by a limited capacity to establish supportive relationships with other people. Difficulties in establishing and maintaining relationships can militate against the development of cooperation with health care providers and may be an important factor in explaining what is often inaccurately described as a "lack of motivation. Distrust —In addition to their distrust of authority, many homeless people are disenchanted with health and mental health care providers. Some have had bad experiences with medications, hospitals, doctors, and other human service professionals and are leery of further involvement.
Except for anecdotal information and obvious indicators of utilization, it is not possible to assess the effectiveness of health care delivery systems for homeless people. There are no adequate data from which such assessments can be made. However, in its review of various programs for health and mental health care services for homeless people, the committee found that four common elements enhanced a program's ability to provide services to this population:. Communication —Those people and agencies involved in the effort to address the health care problems of homeless people interact regularly and frequently.
Coordination —Even if only in a most rudimentary form, there is some way in which clients can be linked with a wide range of existing services i. Targeted Approach —Programs are aggressive in seeking the homeless, rather than passive in waiting for them to appear. This may be reflected by locating a program in a skid row area.
Other programs provide outreach and seek out homeless individuals on the streets. Internal and External Resources —These constitute the range of resources that a program requires to carry out its function adequately, no matter how limited that function might be. Internal resources include reasonable funding and paid employees, in addition to the utilization of volunteers and donated goods and facilities. External resources include both the network of essential services described above and the ability to access that network.
The Health Care for the Homeless projects, funded tly by the Robert Wood Johnson Foundation and the Pew Memorial Trust, are considered by many to have been the single most effective network of health care services developed for homeless people in the s. They are also generally viewed as providing a major impetus for Title Homeless man seeks help health care of the recently passed Stewart B. The first nationwide program to address the health care problems of the homeless, the projects' creation serves as a benchmark. Therefore, this chapter is arranged from the perspective of that unique role.
The following sections of this chapter describe: 1 programs in existence prior to the Johnson-Pew projects; 1 2 the Johnson-Pew program itself; and 3 other programs that came into existence at roughly the same time as the Johnson-Pew projects. The description of the third group is further subdivided, based upon the targeted populations. The final section of this chapter discusses various programmatic, administrative, and clinical issues identified throughout the course of the committee's observation of these service delivery models.
Several program models were developed to provide health care services to homeless people before the mids. The conclusion that they are effective models of service delivery can be drawn from their reported experiences and the fact that the major features of such models appear repeatedly in later programs especially the 19 Johnson-Pew projects.
Shelter-based clinics provide the types of services most frequently found throughout the country. Recognizing a need to bring services to where homeless people can be found, those involved with shelters or health care have developed on-site clinics at shelter locations. These rescue missions are coordinated on the national level by the International Union of Gospel Missions, but there is an even greater strength of coordination locally. Having served the homeless Homeless man seeks help extended periods, they are known to the community and have substantial access to existing networks of, for example, health care services, housing, and social services.
The clinics tend to be staffed by volunteer doctors and nurses and rely heavily on private donations, both of cash and pharmaceutical and medical supplies although some have begun to accept limited financial support from local governments. However, because of the religious aspects of the organizations that operate these clinics, not every homeless person is willing to go to them.
Nonsectarian programs, such as the clinic at the Pine Street Inn in Boston, operate similarly to the religious rescue missions. They have developed strong sources of financial support, frequently from among local businesses, charitable organizations, and foundations. In the absence of any national coordinating or controlling body, they tend to reflect the characteristics and needs of the city in which they are located.
Both the rescue missions and the nonsectarian programs face certain common problems: limited hours many shelters are closed during the daydependence on volunteers, limited access to some of the less common medications, limited specialty and ancillary services e. Both the rescue missions and the nonsectarian programs are, however, major sources of private, not-for-profit, and non-tax-supported health care for homeless people.
Public-private programs share some of the attributes of all volunteer clinics, but they have often resolved some of the problems cited above.
One of the oldest examples is the St. Outreach programs were deed to provide health and social services on-site at SRO hotels and municipal shelters. With some variance according to the site at which services are provided, an interdisciplinary team of a physician, a nurse, and a social worker established on-site medical clinics.
In recent years, partial funding for the program has been received from the New York City Human Resources Administration, that city's department of social services. In addition to the benefits of on-site programming, the clinics and the Department of Community Services at the hospital closely coordinate their efforts. Homeless people referred to the hospital for specialized services are often treated by the same individuals whom they saw at the on-site clinic, improving the continuity of care and increasing cooperation with the care-giver.
Day programs, which are similar to the shelter-based clinics identified above, provide services where homeless people can be found, but they differ from shelter-based clinics in that the sites are independent of residential programs. One good example is St. Francis House in Boston, which has been described by its staff as "a shopping mall of services to the homeless. Included in these services is a health clinic for homeless people that is staffed by volunteers and paid employees. Located in a church in downtown Boston, this is a day program exclusively for elderly homeless people.
Among its services is a food van that stops where the elderly homeless are known to congregate. A registered nurse who is part of the van team performs basic health assessments and referrals for anyone willing to accept this service. A second nurse, stationed at the Medeiros Center, provides more extensive services. The two nurses alternate between the van and the center, so they are familiar with both programs and are readily identified by the homeless people themselves. While the nurse reported to the site visit team that there is little opportunity to perform other than the most basic visual assessment of a homeless person's health status from the van, she indicated that the true value of the program came from gaining the confidence of homeless people and then referring them to the Medeiros Center at a time when she could perform a more detailed assessment.
The fact that they knew her enabled them to overcome any fear that might have prevented them from seeking health care. SinceSOME has been the site for a medical clinic operated by the Columbia Road Physician Group, a group practice composed of four physicians committed to serving homeless and indigent people and providing on-site social services and substance abuse counseling. It has also been the site for a dental clinic operated by the Georgetown University Dental School. In a somewhat different model for the delivery of health care for homeless people was started in Washington, D.
The clinic was funded entirely by donations from individuals, churches, community groups, and small grantors. It used a combination of paid staff and volunteers. It was established as a free-standing clinic in Washington's inner city as a response to the unmet needs of homeless people. People found out by word of mouth that they could receive health care with dignity and without waiting for Homeless man seeks help periods, as they often did in traditional outpatient departments and emergency rooms Bargmann, Although many health clinics have been developed in response to the needs of homeless people, they often also Homeless man seeks help the domiciled poor, especially those who live in the immediate neighborhood.
Other clinics were originally developed to serve poor people in general and now, for various reasons, find themselves serving increasing s of homeless people. Various other programs address the special needs of homeless people or the problems of specific subpopulations among the homeless. One of the most serious issues facing those who work with homeless people is that many standard forms of treatment assume that the patient has a home; when that is not true, treatment is extraordinarily difficult.
Convalescent or respite services allow a homeless person to recover from an illness or an injury that does not require or no longer requires care in a hospital but that is of such severity that the homeless person should not return to a regular shelter setting. One example of a private effort is Christ House in Washington, D. As a result of a bequest, the Church of the Savior acquired and renovated an abandoned apartment house and converted it into a bed respite facility; it has a paid and volunteer staff, including medical and nursing supervision and care.
The Columbia Road Physician Group provides medical support, and all four doctors involved in the project live, with their families, on the top floor of the building, so that medical attention is available around the clock.
When more intensive care is needed, local hospitals are used. A similar program is the bed respite unit at the Charles H. The shelter including the respite unit is funded by the New York City Human Resources Administration and is administered by the Volunteers of America, which is under contract with the city. The respite unit is adjacent to the on-site medical and nursing clinic administered by St. Vincent's Hospital see above and receives nursing support from the clinic. Referral for backup hospital services is either to St.
Many homeless people with physical disabilities, mental disabilities, or both who cannot live independently require supportive living settings. One program that attempts to meet this need is the Veterans Administration VA community placement program, which secures supervised housing for mentally or physically disabled veterans who are facing discharge from a VA medical center and who would be at extreme risk of becoming homeless. Members of the committee visited four such placement sites in Lexington, Kentucky. Three were private homes in which the individual homeowner contracted with the VA to accept patients from the medical center the largest program Homeless man seeks help up to eight men for supervised residential living.
The fourth program was a personal care home d by the Commonwealth of Kentucky.
The personal care home received clients from the state agencies serving the mentally ill and the mentally retarded, as well as from the VA medical center. This facility is larger over 15 beds and was specifically deed to serve a population in greater need of medical and nursing care. Although the residences were supervised and certified by government agencies, the actual funding for the individual veterans comes from their own VA benefits.
In each of the programs identified above, communication and coordination were accomplished by individualized approaches developed over a period of time with systems that were more or less unique to each city. The programs were primarily targeted to the homeless; funding and other resources ranged from the purely charitable to the wholly publicly funded.
However, a comprehensive, cohesive system of services is lacking. Even those programs that had strong ties with a hospital did not network with programs that serve, for example, the mentally ill or substance abusers. The most ificant event to occur in the area of health care for homeless people in recent years was the creation of the Health Care for the Homeless grants, funded tly by the Robert Wood Johnson Foundation of Princeton, New Jersey, and the Pew Memorial Trust of Philadelphia.Homeless man seeks help
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