THE HOMELESS HEALTH OUTREACH AND MOBILE ENGAGEMENT (HHOME) PROJECT
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1 THE HOMELESS HEALTH OUTREACH AND MOBILE ENGAGEMENT (HHOME) PROJECT SAN FRANCISCO, CA funded by: HRSA Special Project of National Significance (SPNS) initiative JASON DOW: peer navigator SIOTHA KING-THOMAS: case manager DEBORAH BORNE, MSW, MD: principal investigator JANELL TRYON, MPH: researcher & evaluator KATE FRANZA, LCSW: program manager JOAN BROSNAN, RN: registered nurse ILONA MARGIOTTA, MSW: medical social worker
2 AGENDA THE LANDSCAPE A SNAPSHOT of HOMELESSNESS in SF MEET the TEAM STAKEHOLDERS DEMOGRAPHICS REFERRALS & COMMUNICATION MOBILE CARE TRANSITIONS OUTCOMES
3 SF Department of Public Health: MEDICAL CLINICS, CONSORTIUM CLINICS, & SHELTERS
4 HOMELESSNESS in SF Average age of death for someone Experiencing Homelessness: 43 years 70 % have a Chronic Illness: Medical or Behavioral Health Issue 2015 Homeless Count people who are chronically homeless: 55% Mental Health Condition 35% Post Traumatic Stress Disorder 62% Have Substance Abuse 43% Chronic Health Problems Data from HUD Funded San Francisco Homeless Count 2009/2011/2015
5 DPH FY : DATA for CLIENTS EXPERIENCING HOMELESSNESS HOMELESS HOMELESS > 10 YEARS TAY WOMEN AGE 60+ TOP 1-5% HIGH UTILIZERS Total Number 9,975 3, ,403 1,304 1,234 % HIV 7.5% (747) 12.3% 2.7% 5.3% 6.6% 13.3% (173) Coordinated Case Management System (CCMS) Homeless Client Data
6 HHOME Team
7 INTEGRATED MOBILE CARE: a citywide collaboration SPNS-grant/HHOME offered a sustainable way to take on an already burgeoning project
8 HHOME PARTNERS & STAKEHOLDERS
9 HHOME: targeting the hardest-to-reach to be considered for enrollment, a client must be: living with HIV experiencing active substance use not adherent to or prescribed HIV Medicine living with mental illness living on the street or in HRSA-defined unstable housing not currently engaged in primary medical care
10 DEMOGRAPHICS
11 PARTICIPATION ENROLLMENT CLIENTS SERVED: 90 in 2 years ENROLLED in STUDY: 61 participants ACTIVE PANEL: 40 For team with 0.2 FTE MD 20 per CM REFERRED: ~ 130 clients
12 REFERRALS HOSPITAL MEDICAL PSYCHIATRIC EMERGENCY ROOM SHORT-TERM/LONG-TERM CARE COMMUNITY PRIMARY CARE URGENT CARE POLICE/JAIL SHELTER/STREET OUTREACH
13 ACUITY and CHRONICITY ASSESSMENT for REFERRALS
14 MOBILE PRIMARY CARE: opportunity to cross-train PRIMARY CARE with MD & MEDICAL SOCIAL WORKER 1. Outreaching CBOs/Streets/Encampments 2. Visiting Hospital/Shelter/SRO 3. Co-located Clinics HIGHEST ACUITY CLIENTS ROUTINE CLINICAL CHECK MEDICAL COUNSELING NURSING & MEDICATION ADHERENCE with RN, Peer, and CM 1. Outreaching CBOs/Streets/Encampments 2. Visiting Hospital/Shelter/SRO 3. Co-located Clinics LOWER ACUITY CLIENTS MEDICATION ADHERENCE for ALL CLIENTS ROUTINE NURSING CHECK
15 MOBILE HOUSING CASE MANAGEMENT HOUSING STATUS DEPENDS on: Readiness of client AND Housing availability (crisis in SF) IT S ALL ABOUT APPROPRIATE LEVEL skilled nursing facility (SNF) emergency shelter treatment/detox street*
16 WHY MOBILE VISITS EVEN/ESPECIALLY WHEN CLIENTS ARE HOUSED clients struggle with being indoors, organization, and creating new routine; most often this housing includes temporary, emergency rooms MOBILE CARE during this time it is crucial that the entire team be available to provide mobile care in the community
17 MOBILE PEER NAVIGATION the ins & outs of navigation relationship building 1. Build RELATIONSHIPS and TRUST 2. Find out their hot spots 3. Learn their substance use history escort clients to appointments Social security GA Medi-Cal Clinical appointments DMV And so on! search and find clients (call hospitals and jails; search the city on foot) Be the first line of contact with new clients
18 CLINICAL OUTCOMES
19 SUCCESSES CHALLENGES Trauma-informed Care Client-centered and System-supported Cross-training of team Starting treatment anywhere, anytime Team Communication Community pharmacy Support of Lead Agencies Not Enough Stabilization or Supportive Housing Not enough Navigation or RN time Lack of Trauma Informed Programs and Providers Lack of communication between hospital and community Courage of consumer and team
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