BY: TARA SKLAR, J.D., M.P.H. AND DONNA ZAZWORSKY, RN, M.S., C.C.M., F.A.A.N.
The challenge of providing health care services to homeless individuals is an issue every community faces, particularly since the needs for housing, food, job training and other basic necessities cross medical, behavioral and social-services lines. Tucson's home- less population tops 4,000 people on any given day, representing one-fifth of Arizona's homeless. These are single men and women, teenagers and families with small children — barely noticed by many and often acknowledged only with disdain by others.
A recent needs assessment by the City of Tucson and Pima County Task Force demonstrated that coordination of care is critical to making the most of efforts by the diverse agencies serving the local homeless population. Carondelet Health Network, which co-chairs the task force, took the opportunity to play a significant role by supporting community efforts to improve the stability, capacity and well-being of homeless individuals. In coordination with local organizations, Carondelet Health Network worked with the network's fundraising arm to secure a financial commitment of $2 million dollars, payable at $400,000 a year over the next five years, from an anonymous donor.
Carondelet Health Network also serves as creator and lead partner in the community collaborative called the Southern Arizona Health Village for the Homeless, which evolved in response to the recent needs assessment. The collaborative brings together a coalition of many different local entities that serve the homeless to focus on an overall goal of providing a seamless health care delivery system.
The next step in addressing homelessness in the area is to establish primary objectives and determine the partners and services necessary to provide such a system for this targeted population. Carondelet Health Network and the initial members of the Southern Arizona Health Village for the Homeless created five objectives with the following specific identified activities to produce measurable outcomes:
- Establish a consortium of partners
- Create the continuum of care
- Increase the number of health care service visits for the homeless
- Improve clinical outcomes of the homeless
- Reduce inappropriate use of emergency department resources
ESTABLISH A CONSORTIUM OF PARTNERS
The first objective was to establish a consortium of partners that includes broad representation and participation throughout the community. These include the Roman Catholic Diocese of Tucson, El Rio Community Health Center, St. Elizabeth's Health Center for the uninsured, Primavera Foundation for the Homeless, Pima Community Access Program for health coverage assistance, Pima County Health Department, Interfaith Coalition for the Homeless, Salvation Army, Dependable Home Health Services, Veterans Affairs and Tucson Planning Council for the Homeless. Partners were identified based on their level of services and commitment to enhancing the health and well-being of the homeless population.
CREATE A DELIVERY SYSTEM
These different partners helped design the second and third objectives for the Southern Arizona Health Village for the Homeless: to create a seamless continuum of care that will increase the number of health care service visits for the homeless in an appropriate setting. The design is based on the Chronic Care Model (Wagner, EH, Effective Clinical Practice 1998; 1:2-4) to ensure the best possible functional and clinical outcomes, as well as to encompass a vast array of services that are primarily mobile because of the target population's limited access to resources and transportation.
The program's flagship effort, which launches in early 2010, will be a 38-foot Bounder RV equipped to provide mobile medical services at sites frequented by the homeless in our community. These sites include shelters, churches and other public areas where the homeless congregate. A nurse practitioner, community health outreach worker and clerical assistant will staff the "Van of Hope." Together, they will provide health assessments, treatment, medications, case management and community referrals. The van also will be equipped with telemedicine technology including an exam camera, ensuring that services such as tele-dermatology, tele-wound care and other consultations can be offered with "real time" or "store and forward" capability.
The health village collaborative will establish designated acute- and extended-care beds in hospitals community-wide; case management and social service outreach to homeless children through the school systems; behavioral health screenings and connection to Carondelet's behavioral health program, which offers 24-hour crisis assessment; and specialized health ministry training to churches and faith-based communities that already make a concerted effort to help the homeless with social services.
IMPROVE OUTCOMES, SAVE COSTS AND EVALUATE
The fourth and fifth objectives of improving clinical outcomes and reducing inappropriate use of emergency department resources are key to addressing the adverse effects of the homeless on the health care system. Significant costs are attributed to inappropriate emergency and inpatient admissions for conditions that are often preventable but highly acute due to lack of primary care.
The Southern Arizona Health Village for the Homeless includes an advisory council drawn from the partners listed above. This council will function as an oversight committee to ensure measurable outcomes are being achieved and oversee ongoing evaluation of clinical and financial reports. A satisfaction tool will be implemented for both patients and providers to ensure patients are treated with dignity and respect and that providers are satisfied with how they are able to deliver care. Other measurable outcomes include the number of patient visits per month made on the Van of Hope, the number of referrals to specialists and medical homes and adherence to medication. Chronic disease management also will be tracked through electronic health record software.
LESSONS LEARNED: SUSTAINABILITY PLAN WITH EXTERNAL FUNDING
Thanks to the generous gift of $2 million dollars from an anonymous donor, the Southern Arizona Health Village for the Homeless services will extend across the many community partners as well as geographic areas. The donor rejected previous proposals for funding because the program lacked integrated sustainability. To address this challenge, the Southern Arizona Health Village for the Homeless proposal provided a reasonable and justifiable budget, plus a three-pronged approach that leverages government and community resources. In this way, the program will continue to have a positive margin after the donation period ends. Sustainability will be ensured due to the following:
- A strong emphasis on enrollment into the state Medicaid plan and ability for the nurse practitioner to bill for services.
- Partnering with government funding sources, including federal programs that support health care for the homeless and the Veterans Administration. In-kind staff time to raise funds and apply for external grant funding is included.
- A 71 percent annual savings for Carondelet Health Network in the amount of $284,293 due to avoidable emergency department and inpatient admissions for Carondelet St. Mary's Hospital. The formula and final amount was calculated through Ascension Health's Return on Community Investment Tool. These significant savings in cost avoidance will help Carondelet Health Network continually reinvest, grow and sustain the Southern Arizona Health Village for the Homeless program.
Jude Magers, senior vice president of mission integration for Carondelet Health Network, noted, "This generous gift and the coordination and cooperation of many partner organizations will make it possible to better serve the medical needs of the homeless population in our community. An effort this big requires the commitment and coordination of a number of agencies, and we are extremely humbled by the cooperation we have received. We are grateful to the many organizations partnering with us in the creation of the Southern Arizona Health Village for the Homeless."
As the community's only Catholic health care provider, Carondelet Health Network is guided by a faith-based mission and calls to action that compel us to respect the dignity and diversity of life and to reach out to people who are vulnerable and underserved — a perfect description for homeless individuals and families.
TARA SKLAR is director of access and community health and DONNA ZAZWORSKY is director of diabetes care and outreach for Carondelet Health Network in Tucson, Ariz.