HCH Directory - Foreword & Introduction

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Health Care for the Homeless Grantee Profiles 2006-2007 is a valuable resource for providers and other individuals interested in health care for homeless people. Profiles 2006-2007 looks at the variety of approaches grantees have employed to overcome the challenges of caring for people with complex medical and support needs.

Health Care for the Homeless (HCH) grantees are supported by the Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care (BPHC) as part of the Health Center Program. BPHC has been funding rural and urban community-based organizations to provide health care services to homeless individuals since 1987. It is a critical and effective resource for the many hundreds of thousands of homeless Americans in desperate need of health and related services. Using Federal dollars combined with other resources, HCH grantees work aggressively to provide primary health care services, substance abuse services, mental health services, oral health services, outreach, case management, and eligibility services.

The 185 grantees profiled herein provide services to well over 600,000 homeless people per year at hundreds of accessible locations in 50 States, the District of Columbia, and the Commonwealth of Puerto Rico.

Although the number of individuals with poor health conditions associated with homelessness continues to increase and resources, financial and otherwise, continue to decline, these organizations remain committed to improving and expanding access to comprehensive health care and social services for homeless people and to eliminating health disparities. Through creative linkages and services, HCH providers demonstrate unquestionable success in providing high quality care to homeless individuals and families in an efficient and cost effective manner.

You are encouraged to use Profiles 2006-2007 to learn about HCH grantees and to build partnerships with others in your community who are committed to meeting the unique health care needs of homeless individuals in a comprehensive, caring, and effective manner.

Using the Directory

The Health Care for the Homeless (HCH) directory is a reference tool for programs and agencies serving the health care needs of homeless people throughout the United States. Its purpose is to foster collaboration and communication among people working in this field.

The 2006-2007 edition of the Health Care for the Homeless Grantee Profiles provides current listings of 185 Health Care for the Homeless grantees, more than 300 subcontractors, and 64 government and private agencies. The information included in these pages is current as of September 2006.

In this publication, subcontractors are defined as organizations that have formal written agreements with grantees to provide services to homeless clients. These organizations receive 330(h) funds through the grantee of record. Subcontractors’ names and addresses are listed in Part 2, Health Care for the Homeless Project Descriptions. Information about the specific services that grantees and subcontractors provide, and the populations they serve, is located in Part 3, Summary of HCH Projects, in Table 3.2.

Many grantees have developed informal relationships with additional provider organizations not considered formal subcontractors. These programs are identified in the Linkages section of the grantee project descriptions located in Part 2 of this directory. Please note these organizations do not appear in any of the tables.

Although Health Care for the Homeless Grantee Profiles 2006-2007 contains a wealth of information, it is beyond the scope of this publication to include a comprehensive listing of all organizations which are of interest to those who provide services to persons who are homeless. Directory users are encouraged to contact the Health Care for the Homeless Information Resource Center at (888) 439-3300 for more extensive listings and information.

If you discover any omissions or errors in the directory, you can use the Additions/Corrections form found at the end of this directory, and submit the correct information to the Health Care for the Homeless Information Resource Center as directed on the form.

Part 1:
Introduction

THE FACE OF HOMELESSNESS

The Urgent Problem

Homelessness continues to be a pervasive problem throughout this country, affecting rural as well as urban and suburban communities. The exact number of individuals living without stable housing in this country is almost impossible to know. According to the most recent national survey, it is estimated that 842,000 people are homeless on a given night and 2 to 3 million are homeless over the course of a year. While the exact numbers are uncertain, it is generally acknowledged that homelessness in the United States is steadily on the rise.

Most homelessness is short-term and people exit homelessness with minimal assistance. But the subgroup that tends to be the most visible is a group of about 200,000 people who experience homelessness on a protracted or repeated basis. On any given night, this group will represent almost half of those who are seeking emergency shelter. Chronically or repeatedly homeless, they frequently have one or more serious and disabling health conditions, including mental health and/or substance use disorders, all of which present a complex set of challenges to service providers.

Why are people homeless? There are a variety of conditions that contribute to an individual or family becoming homeless. Underlying all homelessness are the conditions of poverty, particularly inadequate income, and the lack of affordable housing.

People with little or no income have difficulty accessing affordable housing. The U.S. Department of Housing and Urban Development (HUD) estimates that there are 5 million households in the U.S. with incomes below 50 percent of the local median who pay more than half of their income for rent and/or live in severely substandard housing. This is worsened by a decline in the number of housing units affordable to extremely low-income households and the limited availability of Federal rental assistance to bridge the gap.

In addition to poverty, there are also health and social factors that increase an individual or family’s vulnerability to becoming homeless. Some of these factors include acute and chronic physical health problems or disabilities, mental illnesses (both chronic and acute), substance use problems, domestic violence, or history of abuse or neglect.
The thousands of men, women, and children who experience homelessness are challenged at nearly every turn in their daily struggle to survive. Whether concentrating on finding a meal or a place to sleep, they must maneuver through a series of support systems, always hoping that they will not fall through the cracks.

The Comprehensive Response

In 1987, the Stewart B. McKinney Homeless Assistance Act, Public Law 100-77, was enacted to provide relief to the Nation’s rapidly increasing homeless population. The intent of the Act was to provide funding for emergency food and shelter, education, and transitional and permanent housing, as well as address the multitude of health problems faced by people who are homeless. Title VI of the McKinney Act added Section 340 to the Public Health Service (PHS) Act, authorizing the Secretary of Health and Human Services (HHS), acting through the Health Resources and Services Administration (HRSA), to award grants for the provision of health care to homeless individuals.

The addition of Section 340 to the PHS Act established the Health Care for the Homeless (HCH) program, the only Federal program with responsibility for addressing the primary health care needs of homeless people. In 1996, the Health Care for the Homeless program was re-authorized as Section 330(h) of the Health Centers Consolidation Act (HCCA), which amended the PHS Act by consolidating the HCH program with other community-based health programs. The HCCA was re-authorized in 2002.

The HCH program was modeled after a successful 4-year demonstration program operated in 19 cities by the Robert Wood Johnson Foundation and the Pew Charitable Trust. The demonstration emphasized a multi-disciplinary approach to delivering care to homeless persons, combining aggressive street outreach with integrated systems of primary care, mental health and substance abuse services, case management, and client advocacy. Particular emphasis was placed on coordinating efforts with other community health providers and social service agencies.

The demonstration program confirmed that the health status of homeless people is far worse than that of the general population. The program also demonstrated that people who are homeless can be reached by emphasizing outreach and offering targeted, flexible services in locations where homeless people can be found, including shelters and soup kitchens.

Building on the experience of the national demonstration, HCH grants have made it possible for other communities to make primary care, mental health, and substance abuse services accessible to people experiencing homelessness throughout the United States. There is a critical need for programs that are specifically targeted to provide health care to this underserved segment of society.

Although homeless programs have much in common with other community-based health care providers serving underserved populations, they are markedly different. People who are homeless suffer from health care problems at more than double the rate of individuals with stable housing. This is exacerbated by the multiple barriers that they experience in trying to access mainstream health care, including a lack of transportation and limited hours of service. When people who are homeless do attempt to access services, they often do not have the financial resources (health insurance, Medicaid, etc.) to pay for care. In addition, many have significant mental health and/or substance abuse problems, for which needed treatment services are unavailable from traditional providers. As a result, they become increasingly disenfranchised from mainstream services and are frequently distrustful of traditional health care and social service systems.

HRSA recognizes the complex needs of people who are homeless and encourages participating programs to integrate both health care and social services into individual care plans. HCH grantees strive to provide a coordinated, comprehensive approach to the care they provide their homeless clients, and in such a way that welcomes these clients as patients. Specifically, HCH programs provide for:

• Primary health care and substance abuse services at locations accessible to people who are homeless;

• Emergency care with referrals to hospitals for in-patient care services and/or other needed services; and

• Outreach services to assist difficult-to-reach homeless persons in accessing care, and provide assistance in establishing eligibility for entitlement programs and housing.

To increase access to services and resources for people who are homeless, HCH grantees are encouraged to develop, or actively participate in, local coalitions of health care providers and social service agencies. These collaborations help ensure the adequate and appropriate delivery of services to HCH clients. This involvement has been important in identifying community resources for the provision of shelter, food, clothing, employment training, and job placement for homeless individuals. HCH grantees obtain commitments from other community providers for social service support and seek financial contributions to expand the scope of their programs.

The goal of HRSA is to support HCH grantees to improve the health status and outcomes for homeless individuals and families by improving access to primary health care, mental health services, and substance abuse treatment. Access is improved through outreach, case management, and linkages to services such as housing, benefits, and other critical supports. HCH providers must seek ways to create new approaches to deliver comprehensive care, unite providers through collaboration, and decrease fragmentation of human services.

The Appropriation

Within 4 months of the signing of the McKinney Act in 1987, HRSA awarded 109 grants to initiate HCH projects in 43 States, the District of Columbia, and the Commonwealth of Puerto Rico. The first programs received their initial awards in 1988, and became fully operational HCH projects in 1989.

For FY 2006, $145 million was appropriated by Congress for Health Care for the Homeless grants. This has enabled HRSA to continue funding existing programs as well as add new programs. In FY 2006, 4 new grantees were added. As evidenced in Table 1, Federal funding has continued to increase since 1990 to assist local programs in meeting the health care needs of people who are homeless.

Table 1. Federal Assistance for HCH Grants

HCH Successes

Over the past 20 years, HCH grantees have successfully developed innovative networks and collaborations that maximize both the quality and number of services they provide. Additionally, these linkages have improved the delivery of comprehensive care by enhancing the diversification of services made available to homeless clients.

One of the reasons for the success of Health Care for the Homeless is its flexibility. A variety of community-based organizations support HCH activities. 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. Each individual program determines which service delivery system or combination of systems is appropriate for the people it serves. The diversity in needs and the variety in local service delivery systems have led to diversity in HCH program models. Programs provide services in a variety of different settings, including traditional clinic sites, shelter-based clinics and mobile units. In addition, they take health care services to locations where homeless individuals are found, such as streets, parks, and soup kitchens.

HCH Clients

In calendar year 2005, HCH grantees served 653,318 men, women, and children. Below is a brief snapshot of HCH clients:

• The majority, 57 percent, were male; 43 percent were female.

• Most, 49 percent, were between 20 and 44 years old, followed by individuals between 45 and 64 years old (31 percent). Children and youth up to age 19 accounted for 17 percent. People over 65 comprised 2 percent of clients.

• HCH clients were racially and ethnically diverse:
African-American – 39 percent
Caucasian – 36 percent
Hispanic – 22 percent
Asian/Pacific Islander – 2 percent
Native American/Alaskan Native – 2 percent

• Forty-five percent of clients seen by HCH grantees lived in shelters; 16 percent doubled up with family or acquaintances, 10 percent lived in transitional housing, and 10 percent lived on the street. The remainder was in some other type of living arrangement.

• The majority, 70 percent, of homeless clients had no medical care resources. Approximately 30 percent had some type of insurance: 22 percent were enrolled in Medicaid; 3 percent were enrolled in Medicare; 2 percent had private insurance; and 3 percent received some other type of public insurance.

• Where income was known, 92 percent of homeless clients were living at or below the Federal Poverty Level.

As the health care and social service needs of homeless people have become more complex, Health Care for the Homeless grantees strive to create new approaches to reach and care for their clients. The following section, Part 2, details how each of the 185 HCH grantees delivers care to their clients, and identifies other subcontracting and collaborating organizations that are critical to ensuring quality in the continuum of care that each patient receives.