Core Competencies in the HCH Setting: A Guide for Administrators
Note: This guide is a work in progress and open for comments. If you have any questions, comments or suggestions, please email Victoria Raschke, Director of Technical Assistance and Training, at email@example.com.
Table of Contents
- Health Care for the Homeless 101
- High Priority Clinical Issues
- Substance Abuse, Mental Health Disorders and Cognitive Impairments
- Trauma-Informed Care
- Complex Co-Morbidities
- Developing Relevant, Patient-Centered Treatment Plans
- Motivational Interviewing
- Care Coordination
- Self Care
Special thanks to the Core Competencies Work Group:
Heather Barr, BSN, RN, King County Dept. Public Health, Seattle, WA
Mollie Bresnahan, MEd, LMHC , Health Care for the Homeless/Mercy Medical Center, Springfield, MA
Jan Caughlan, MSW, LCSW-C, Health Care for the Homeless, Inc., Baltimore, MD
Brian Colangelo, LCSW, Project H.O.P.E , Camden, NJ
Bernadette Creaven, MN, RN, Carolyn Downs Family Medical Center, Seattle, WA
Darlene Jenkins, DrPH, CHES, National Health Care for the Homeless Council, Nashville, TN
Alona Koehler, Healthpoint Community Health Clinic, Renton, WA
Greg Morris, PA-C, Peak Vista Community Health Centers, Inc., Colorado Springs, CO
Marcia Stone, MPH, RN, King County Dept. Public Health, Seattle, WA
Additional thanks to the following individuals for their contributions:
Melissa DaSilva, MS, RN, National Health Care for the Homeless Council, Nashville, TN
Victoria Raschke, MA, National Health Care for the Homeless Council, Nashville, TN
Addressing the challenges of healthcare delivery to persons experiencing homelessness requires a commitment to client-centered care, infused with compassion and a creative drive to re-design the service delivery systems for health care and housing. Preparing health care professionals in the HCH setting to take on these tasks requires orientation to the fundamentals of the HCH model of Care and ongoing mentoring and professional development in effectively addressing the needs of vulnerable populations. The Core Competencies Work Group of the Clinicians’ Network recognized the importance of preparing new staff to be effective in the HCH setting and thus endeavored to package the most pertinent training materials and resources in this guide for administrators.
We look forward to your comments.
1. Health Care for the Homeless 101
HCH 101 is a 7-hour training which provides an introduction to the realities of homelessness, the methods of providing health care for this special population, and the large community of HCH consumers, providers, and advocates. The history of HCH is reviewed, the characteristics of the HCH Model of Care are defined, and resources, including those for self-care and team-care, are explored. HCH 101 is beneficial for those new to the health care for the homeless field as well as volunteers and advocates looking for refreshers. HCH 101 presents the basics of homeless health care services including information on outreach and clinic encounters and the implementation of evidence-based methods and techniques that help to foster consistent follow- for persons experiencing homelessness. Motivational Interviewing, Trauma Informed Care, and Provider Self-care are just a few of the cornerstone methods and techniques employed in the HCH setting. HCH 101 includes information from the perspective of the outreach worker, healthcare provider, and persons experiencing homelessness. HCH 101 provides a foundation on which to build new staff orientation and ongoing training to be effective in the HCH setting.
- Staff will be able to list three hallmarks of the HCH Model of Care.
- Staff will be able to list three resources for HCH providers.
- HCH 101 Online Self-Paced Course - The National Healthcare for the Homeless Council has developed an online training tool for those new to the HCH setting as a means of learning the basics of HCH proficiency from the view of the homeless person, advocate, and practitioner. It consists of a pre- and post-test [in redevelopment]. Modules are dedicated to specific topics important in establishing a foundation for new and prospective HCH staff. Viewpoints are presented from the people experiencing homelessness, outreach workers, and practitioners to help ensure success and longevity in the field of Homeless Healthcare.
- HCH 101 may be presented as a live training for your program or a group of programs. Request a training.
- www.CaringwithCompassion.org – An online curriculum developed by University of Michigan that consists of didactic content divided into modules (complete with pre- and post-testing) as well as a low-risk game in which providers can interact with a “patient” in order to drive home the importance of assessing psychosocial factors, working with patients who are under-insured, and inclusion of the patient in creation of treatment plans. There is also a resource section which has links to different organizations as well as a pocket tri-fold which were developed for providers/students to guide them in terms of care and documentation.
2. High Priority Clinical Issues
High priority clinical issues in the HCH setting include housing and employment as well as medical conditions found in the general population. Further, HCH providers must be alert to emerging and urgent clinical situations such as outbreaks of infectious disease, injury related to environmental conditions, and demographic shifts among those experiencing homelessness, such as and increase in families experiencing homelessness. Developing this core competency in no way differs from what is expected by any other specialty healthcare practice or professional healthcare associations. It is the responsibility of the homeless provider to dedicate the time and effort to obtain this information for use in their Healthcare for the Homeless setting. Keeping abreast of the latest news in the HCH field can be daunting. Start by signing up for free subscriptions to newsletters and updates from the NHCHC, CDC, your State Department of Health and your professional organization (AMA, ANA, NASW, among others).
- Staff will be able to list three common diagnoses among HCH clients.
- Staff will be able to list three resources for more information on frequently encountered clinical issues in the HCH setting.
- The National Health Care for the Homeless Conference and Policy Symposium and Regional Trainings - Workshops on topics of high priority clinical importance and presentation of research or studies specific to the care of persons experiencing homelessness. Conference occurs in May annually, with an exception for 2013 when it will occur March 14-16. Regional Trainings occur three times a year in various locations throughout the country. Check the website regularly for updated events.
- Healing Hands - Healing Hands is a quarterly newsletter produced by the Communications Committee of the HCH Clinicians’ Network. You can view the archives in both chronological and subject order on the website. CEUs are available for the current year’s issues.
- Adapting Your Practice Guidelines - Adapted clinical guidelines have been developed on a number of clinical topics, including asthma, diabetes and chronic pain management.
- National Health Care for the Homeless Council Webinars - All Council webinars are archived on the site and new webinars are delivered monthly.
3. Managing Substance Abuse, Mental Health Disorders and Cognitive Impairments
Substance Abuse: A common stereotype of the homeless population is that they are all alcoholics or drug abusers. The truth is that a high percentage of homeless people do struggle with substance abuse, but addictions should be viewed as illnesses and require a great deal of treatment, counseling and support to overcome. Substance abuse is both a cause and a result of homelessness, often arising after people lose their housing.
Although obtaining an accurate, recent count is difficult, the Substance Abuse and Mental Health Services Administration (2003) estimates, 38% of people experiencing homelessness were dependent on alcohol and 26% abused other drugs. Alcohol abuse is more common in older generations, while drug abuse is more common among youth and young adults (Didenko and Pankratz, 2007). Substance abuse is much more common among people experiencing homelessness than in the general population. According to the 2006 National Household Survey on Drug Use and Health (NSDUH), 15% of people about the age of 12 reported using drugs within the last year and only 8% reported using drugs within the past month.
Mental Health: Approximately 20-25% of the single adult homeless population suffers from some form of severe and persistent mental illness (National Resource and Training Center on Homelessness and Mental Illness, 2003). While 22% of the American population as a whole suffers from mental illness, a small percentage of the 44 million people who have a serious mental illness are homeless at any given point in time (National Institute of Mental Health, 2005)
Cognitive Impairments: Cognitive disabilities are functional impairments associated with disorders of the brain, resulting from trauma, mental illness, chronic substance abuse, developmental disabilities, diseases, or toxic agents that affect the central nervous system.
- Screen and Assessment
- Validated tools and measures: DAST, MAST, SBIRT, CAGE/UNCOPE, AUDIT, URICA, NMASSIST, PHQ9, GAD7, SIGECAPS, MMSE, RBANS, MOCA, OSU TBI-ID
- Sign and symptoms
- Risk factors
- Knowledge of various modalities
- Psychopharmacology, Addiction pharmacology
- Behavioral interventions
- Harm reduction
- 12-step model
- Recovery model
- Case management
- Coordination of Care in the HCH setting
- Personal bias
- For possible discussion: Prevention
- Staff will be able to describe the prevalence of substance use and mental health conditions among HCH clients.
- Staff will be able to list up to three tools and measures for screening and assessment.
- Harm Reduction Training – an online course developed by the National Health Care for the Homeless Council
- Documenting Disability – an online course developed by the National Health Care for the Homeless Council
- The Neurobiology of Addiction – an online course developed by the National Health Care for the Homeless Council (CEUs are currently available)
- Healing Hands, “Caring for Clients with Comorbid Psychiatric and Medical Illnesses“ (Dec 2009)
- Healing Hands, “Meeting the Challenge of Comorbid Mental Illness & Substance Related Disorders” (Feb 2009)
- Healing Hands, “Traumatic Brain Injury: Emerging Tools for Assessment and Care“ (Feb 2008)
- Healing Hands, “Dealing with Disability: Cognitive Impairments & Homelessness” (March 2003)
- Substance abuse and homelessness: http://www.nationalhomeless.org/factsheets/addiction.pdf
- Mental health and homelessness: http://www.namhpac.org/PDFs/homeless.pdf
4. Providing Trauma Informed Care
Many individuals seeking homeless services are trauma survivors [citation forthcoming]. Homelessness itself is a traumatic experience and being homeless often increases the risk of further victimization and retraumatization.
Traumas can include: interpersonal violence (both experienced or witnessed), physical, sexual and institutional abuse or neglect, intergenerational trauma, and war, terrorism, and natural disasters that induce powerlessness, fear, recurrent hopelessness, and hypervigilance.
Traumatic experiences may impact an individual’s ability to seek medical and behavioral health services as well as impact an individual’s ability to leave homelessness and remain in stable housing.
The goal of trauma informed care is to avoid retraumatization and exacerbation of trauma symptoms in patients who have experienced trauma in their lives. Becoming trauma informed means implementing and adopting a holistic view of care and recognizing the connections between housing, employment, mental and physical health, substance abuse and trauma history. Trauma informed services “create an environment that acknowledges the impact of trauma and tries to create a sense of safety.” Grant (2010).
The core principles of a trauma informed culture include: safety, trustworthiness, choice collaboration and empowerment.
- Safety - ensuring physical and emotional safety
- Trustworthiness - maximizing trustworthiness, making tasks clear, maintaining appropriate boundaries.
- Choice - prioritizing consumer choice and control over recovery.
- Collaboration - maximizing collaboration and sharing power with consumers
- Empowerment - identifying what patients are able to do for themselves; prioritizing building skills that promote recovery; helping consumer find inner strengths needed to heal. Beyer (2010)
- Staff will be able to identify techniques for delivering trauma informed services to clients.
- Staff will gain familiarity with techniques for creating a safe environment for clients that acknowledges the impact of trauma in their lives.
- Beyer, L.L., and Blake,M. (2010). Trauma-informed care: Building partnerships and peer supports in supportive housing settings [PowerPoint slides]. Presentation at Services in Supportive Housing Annual Grantee Mmeeting. Washington, DC. Retrieved from http://www.samhsa-ssh-meeting.net/assets/documents/trauma_informed_care.pdf
- Grant, G. (2010). Truly trauma-informed: Assessing the agency through the trauma lens [PowerPoint slides]. Presentation at Practice in Progress: Expanding Skills in Trauma Work. Second Annual Trauma Conference. South San Franscico, CA. Retreeived from http://www.co.sanmateo.ca.us//2010TraumaCOnferencePresentations/TraumaConf_Grant.pdf
- Healing Hands, “Delivering Trauma-Informed Services” (Dec 2010)
- SAMHSA Homelessness Resource Center. Trauma Informed Care 101. Kathleen Guarino
5. Managing Complex Multiple Morbidities
Multiple morbidities are commonly encountered among persons experiencing homelessness. Having to manage multiple morbidities in the homeless population is an integral part, if not a standard of care, for anyone providing healthcare in this setting. There is much information (online and in prominent periodicals) on the definition of co-morbidities and models of care that are broader than the focus considered necessary in the Homeless Healthcare setting.
It is very difficult to treat a homeless person with increasing multiple health issues in which external variables often determine the efficacy in producing good clinical outcomes. These factors include a coexisting mental health disorder, lack of resources, different set of priorities influencing the ability to maintain tight controls for certain health issues as determined by professional medical societies, research, or UDS guidelines. There is information on complex co-morbidities within multiple documents, or case studies within the Councils resources achieves. There is an effort now to provide a resource to guide clinicians in the effort to manage multi-morbidities in this difficult population.
- Staff will be able to identify three external variables that often determine the efficacy of producing good clinical outcomes for people experiencing homelessness.
- Staff will be able to identify three resources on how to manage patients with complex co-morbidities.
6. Developing Relevant, Patient-Centered Treatment Plans
A Treatment Plan should provide all of the information necessary for a conscientious person to deliver the correct treatment procedures, at the correct times, and with sufficient consistency to produce the changes in behavior that are described in the Plan — reducing or eliminating undesirable behavior and increasing or improving desired behavior, while providing a means to monitor progress on an ongoing basis that informs the process of treatment.
Treatment plans are strategies designed to guide health care professionals involved with patient care. Such plans are patient specific and are meant to address the total status of the patient. Care plans are intended to ensure optimal outcomes for patients during the course of their care.
- Stay focused on the person not the problems
- Transformation through relationships, not paperwork
- Legal compliance
- Components to include:
- A prioritized list of main concerns/goals with
- The current clinical/educational/social information pertinent to the concern/goal.
- The current plan/intervention for that concern/goal
- The person(s) responsible for that intervention
- The due date for the intervention
- Realistic xxpectations of both patient and medical provider
- Assess motivational readiness
- Patient-Centered Medical Home Compliance
- Interdisciplinary approach – Medical, nursing, social work, psychiatrist, outreach
- Assignment of responsibilities
- Ability to collaborate and work as a team
- Provider skills
- Patient engagement
- Obtaining patient “buy-in”
- Providing Education
- Staff will be able to list up to three components of a treatment plan.
- Sample treatment plans, National Health Care for the Homeless Council
- Principles for Patient- and Family-Centered Care , National Partnership for Women and Families
- When Do Patients and Their Physicians Agree on Diabetes Treatment Goals and Strategies, and What Difference Does It Make?, US National Library of Medicine, National Institutes of Health
- The influence of patient-practitioner agreement of outcome of care, US National Library of Medicine, National Institutes of Health
Among the many core competencies of service to individuals experiencing homelessness is the competency in the field of conducting outreach and engaging clients. Outreach is defined as moving health services beyond the walls of traditional medical institutions and into the community, streets, soup kitchens, shelters, bridges, and locations where the most underserved are to be found. Health services that are delivered in outreach settings include medical health, mental health, and social services such as health insurance enrollment and benefits enrollment (Social Security).
By breaking down psychological and systematic barriers to care, individuals experiencing homelessness are provided care through the creative and nontraditional means of delivery. Vital to the core of outreach are the following elements: rapport and relationship building, disseminating information and services (medical, mental health and case management) in a flexible manner and in the location where the patient is most comfortable, patience in motivating clients and the use of a multidisciplinary team.
- Staff will be able to describe outreach as a healthcare strategy.
- Staff will be able to identify three resources that provide more information on outreach.
- Outreach Resources Page, National Health Care for the Homeless Council
- Outreach to People Experiencing Homelessness: A Curriculum for Training Health Care for the Homeless Outreach Workers (2005) National Health Care for the Homeless Council – The purpose of this curriculum, developed by Ken Kraybill, is to provide a comprehensive overview of the principles, knowledge and issues relevant to doing outreach in the Health Care for the Homeless context. It is intended to serve as a guide for anyone involved in facilitating training for outreach workers in Health Care for the Homeless settings and other outreach programs.
- Mobile Medical Outreach: A Commitment to Service (2009) - This homeless health care case report, developed by the HCH Clinicians’ Network, elucidates components of mobile medical outreach treatment, highlighting best practices and evidence-based primary care. The report presents a compelling case submitted by Outside In Community Medical Outreach in Portland. Oregon. It discusses engagement, continuity of care, social service advocacy, supportive housing, the use of Model for End-Stage Liver Disease (MELD) scoring and the Short Alcohol Dependence Data Questionnaire (SADD).
- Mobile Health Care for Homeless People: Using Vehicles to Extend Care (2007) - This report describes the experiences of 33 HCH projects that use outreach vehicles, ranging from passenger vans to custom-designed clinics on wheels, to provide a variety of health services to people without stable housing. Topics discussed include the rationale for mobile health outreach to homeless populations, services provided and staffing models, types and designs of mobile units, financing and administration of mobile health programs, obstacles encountered and strategies used to address them, and factors to which HCH providers attribute the success of these mobile outreach efforts.
- Organizing Health Services for Homeless People: A Practical Guide (Second edition), Marsha McMurray-Avila (2001) – See Part 4: Service Delivery Strategies; F: Outreach. Available from Amazon.com.
- Healing Hands, “Keeping Homeless People Out of the Justice System: The HCH Role” (Dec 2004)
- Healing Hands, “Hard to Reach: Rural Homelessness & Health Care” (Oct 2001)
- Healing Hands, “Operation Safety Net: Outreach to Unsheltered Homeless People” (Nov 1998)
8. Motivational Interviewing
Developed by Professors William R. Miller and Stephen Rollnick, Motivational Interviewing is used extensively by Health Care for the Homeless providers. It is semi-directive, client-centered counseling style for eliciting behavioral change. It helps clients explore and resolve ambivalence in order to elicit behavioral change. The resolution of ambivalence is a central concept. It was originally developed to assist people with alcohol dependence. Motivational Interviewing is supportive, not argumentative, nonjudgemental and non-confrontational.
The basic principles of Motivational Interviewing include:
- Expressing empathy through reflective listening
- Developing and exploring discrepancy between clients’ current behaviors and their goals or values
- Avoiding confrontation and argument with the client
- Adjusting or rolling with client resistance
- Supporting self-efficacy and optimism
Motivational Interviewing assists in increasing the client’s awareness of the risks and consequences of their behavior and possible benefits of change. It helps motivate the client to make a change that is consistent with their values or goals.
- Staff will be able to list up to three principles of Motivational Interviewing.
- Staff will be able to identify three resources on additional information pertaining to Motivational Interviewing.
- Motivational Interviewing, online introductory course, National Health Care for the Homeless Council
- Motivational Interviewing: An Overview with Application in Outreach in the HCH Setting, archived webinar, National Health Care for the Homeless Council
- Motivational Interviewing, article by Janet Treasure, Advances in Psychiatric Treatment
- Motivational Interviewing: Drawing Out the Homeless, article, Everything Addiction
- Spotlight on PATH Practices and Programs: Motivational Interviewing, SAMHSA
- MI Basics, collection of resources at www.motivationalinterviewing.org
- Motivational Interviewing in Health Care, book, Stephen Rollnick and William R. Miller, authors
9. Principles of Care Coordination
Persons experiencing homelessness burdened with complex commorbidities, often require a good deal of care coordination. Care coordination is defined by NCQA as:
- A function that supports information-sharing across providers, patients, and types and levels of service, sites and time frames.
- The goal of coordination is to ensure that patient’s needs and preferences are achieved and that care is efficient and of high quality.
- Care coordination is most needed by persons who have multiple needs that cannot be met by a single clinician or by a single clinical organization, and which are ongoing, with their mix and intensity subject to change over time.
Providing holistic care to individuals with complex medical and behavioral diagnoses adds a layer of complexity to care coordination, particularly when there is controversy over treatment approaches. Disagreements over treatment approaches are common, inclusive of both perceived priorities as well as treatment approaches. Communication skills are primary and woven throughout the entire process. Additionally, care coordination is enhanced when providers are skilled in 2 specific areas:
- Referral Capacity
- Good listening skills
- Ability to appreciate the values or experiences expressed in the opposing view
- Knowing which conflicts to resolve
- Validated knowledge of the treatments being negotiated.
- Having good working relationships with one’s colleagues
Learning to be a good negotiator is something that gets better with practice. Being able to resolve treatment conflicts between providers allow the team and the client work out the best plan of care.
- Staff will be able to identify the definition of :Care Coordination: as defined by the National Committee of Quality Assurance (NCQA).
- Staff will be able to identify additional resources on care coordination.
- Case Study in Care Coordination, Jan Caughlan, MSW, LCSW-C, Supportive Housing Director, Health Care for the Homeless, Baltimore, MD (June 2012)
- Meaningful Measures of Care Coordination, Sarah Hudson Scholle, Assistant Vice President, Research, National Committee on Vital and Health Statistics, NCQA (Oct 2009)
- Integrating Harm Reduction into Drug and Alcohol Treatment, online training course, Statewide Partnership for HIV Education in Recovery Environments (SPHERE), availability varies
10. Self Care
- Self Care for the Homeless Health Care Provider, podcast series, National Health Care for the Homeless Council
- Healing Hands, “Renewal and Resiliency in Our Work” (Feb 2002)
- Healing Hands, “HCH Staff Recruitment and Retention: Unique Problems, Innovative Solutions” (June 2007)
- Healing Hands, “The Presence of Spirituality in Healing“ (Aug 2008)
- Healing Hands, “Compassion Fatigue: The High Cost of Caring” (Winter 2012) (CEUs currently available)
- What About You? Tools to Promote Self Care, webcast. Homeless Resources Center (Jan 2010)