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Envelopes of care: healthcare for Boston's forgotten families

The Boston Health Care for the Homeless Program's Family Team provides access to high-quality health services for homeless families

Case manager Crystal Belchior, right, talks with Raquel Gonzales, a resident at the Crossroads Family Shelter in East Boston, about her baby Jasmiah. (David Stone for On Call) Case manager Crystal Belchior, right, talks with Raquel Gonzales, a resident at the Crossroads Family Shelter in East Boston, about her baby Jasmiah.
By Janet M. Cromer, RN
April 24, 2008
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Toya Scott, ADS, BSN, is setting up her table in the living room of a converted home in Dorchester that now serves as a shelter for homeless families. As she does, a wheezing 4-year-old with asthma takes a seat. His worried mother looks on and asks questions as Scott explains how to use the inhaler and when to bring the boy to the emergency department. Scott is a maternal/child health nurse on the Family Team at Boston Health Care for the Homeless Program (BHCHP). Over the course of the morning, she teaches a pregnant teen about good nutrition. She shows a mother how to remove head lice. And she helps a father get medication for his son's type 1 diabetes. With every encounter, she imparts important health information to the people who come to see her. And it's all delivered with respectful attention to her clients' needs.

The scope of family homelessness in Boston

According to the Massachusetts Coalition for the Homeless, more than half of the homeless people in Massachusetts are parents and children, and nearly 3,000 children stay in shelters every year. In December 2007, the City of Boston's annual Homeless Census counted 6,901 homeless men, women, and children. Included in that figure are 3,084 families and 1,849 children. When compared to the 2006 census, those numbers represent a 17 percent rise in the number of homeless families. They also represent a 21 percent rise in the number of homeless children.

People lose their homes for many reasons — poverty, domestic violence, job loss, mental illness, substance abuse, fires, and death of a family member. In addition, the current crisis in housing foreclosures is forcing many renters to become homeless. Family Team nurse Toni K. Williams, RN, says no matter what circumstances lead to homelessness, it is important to see how traumatizing this is for families and children.

According to Williams, nurses may have patients in their regular clinical practice who have lost their home. But they may be too devastated to disclose this information. With the increasing rate of homelessness, she says, it's incumbent on nurses to ask each patient they see, "Where are you living?"

Bringing care directly to clients

Founded in 1985, the Family Team was one of the first services offered by BHCHP. The team comprises two RNs, two family nurse practitioners, a physician's assistant, a licensed mental-health counselor, and a social worker. Each year, the team provides care to 1,800 homeless parents and children. To ensure those families have access to services they need, Family Team nurses work closely with social-service agencies, the Department of Transitional Assistance, Boston Public Health Commission and the Centers for Disease Control.

The team uses an outreach model to work with this growing and widespread population, bringing services to 47 sites around Greater Boston. Those sites include family shelters, domestic-violence shelters, residential treatment programs, medical facilities, and day-care centers. Mental health services and substance abuse counseling are an integral part of those services at every site.

Building trust and continuity of care

The BHCHP team offers a stable presence in a world of instability. After shelters contract for the team's services, a predictable visit schedule using consistent staff is established and maintained. Williams says nurses set up a table to talk with clients and go door to door in the family shelters to let people know they are available.

The initial needs assessment BHCHP conducts with a family covers health concerns, immunizations, acute care, and referrals. The team also helps homeless clients obtain legal and mental health services as well as information about financial assistance programs. Scott says that building trust can take weeks or months because of the trauma and debilitating circumstances many people have experienced.

Some shelter residents will observe Scott's interactions with their friends for a few visits before seeking her assistance. Scott says she has learned that one essential step to building trust is to meet the client on the client's own terms. "We need to allow the client to tell us what he is capable of doing, and what he wants from us," she says. "We have to allow the client to direct her own care even if we have different ideas."

The consequence of trying to impose an agenda, Scott says, is frustration and burnout for both the client and the nurse. The team needs to understand and deal with the fact that a young woman struggling with substance abuse may accept the nurse's offer of a bandage for the gash on her forehead, but decline a detox referral. When referrals are made and followed through with, however, the electronic medical record that BHCHP implemented in 1996 facilitates communication and safe treatment among all providers.

In an effort to provide continuity of care, BHCHP has developed many collaborative programs and clinics with Boston Medical Center. Williams says, "We provide an envelope of care to wrap around homeless children and families."

Challenges of homelessness for children

The BHCHP Family Team cares for every family member. But the main focus of their efforts is on women of reproductive age and their children.

In a family shelter, according to Williams, families have their own bedroom. But the kitchen, bathroom, and living room are congregate areas. She says children living in such a shelter face a range of health, developmental, and psychological challenges. Children are at increased risk of influenza, norovirus, upper respiratory infections, and infectious illnesses that can circulate in these communal conditions. There is also the potential for developmental delays because there is not enough space for a younger child to crawl or run around, which can hinder motor development.

For parents, there's the stress of living in a "fishbowl" environment. Shelter staff may correct the parent in front of the child, leaving the child unsure about who is in charge. Sometimes staff members at shelters are well intentioned, but unaware of what is developmentally appropriate behavior or play. The Family Team nurses educate family members and assist shelter staff with training needs when invited.

While the average stay in a shelter was 9 to 12 months a few years ago, it's now more often 18 months. As a result, there is a higher incidence of stress-related illness in parents, and an increase in the number of children who present as stressed or depressed. Williams has noticed that children as young as first or second grade sense something shameful about being dropped off the school bus in front of a shelter.

A repertoire of clinical and lifestyle skills

Family Team nurses care for children ranging from newborns to teens, and say the most common element in that care is education. They teach about symptoms and what they mean. They show how to care for self-limiting illness. And they help families understand developmental stages and needs.

Williams says that when she examines an infant, she talks to the mother about the benefits of breastfeeding for imparting immunity. She talks about not letting shelter guests hold the child before they wash their hands. She also focuses on the fact that the child is constantly developing and changing.

Meeting a toddler's nutritional needs and preferences within the limits of shelter provisions is another important area that the nurses have to address. Williams gives out countless thermometers; she also watches for dehydration, viral illness, and early signs of methicillin resistant staph infection (MRSA).

Boston's high asthma rates are echoed in the shelter population. Scott teaches parents to pay attention when their child says he's "tight," and complains of other unobservable symptoms. The nurses follow the 2007 Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, which helps parents understand the importance of good asthma-management skills.

Adolescents are offered confidential visits where a nurse can inquire about risky behaviors. They also use this opportunity to teach about HIV and sexually transmitted diseases.

Williams says other conditions the Family Team nurses deal with include juvenile and gestational diabetes, HIV-related problems, injuries, scabies, and wounds. Last year, there were even a few cases of pertussis and drug-resistant TB.

Williams says that, in order to be effective, nurses who work with homeless families need top-notch assessment skills and a solid grounding in med-surg nursing, prenatal care, pediatrics, parenting skills, mental health, and dermatology.

Overcoming adversity

Scott attributes the longevity of service of BHCHP clinicians to their commitment to homeless people. That commitment, she says, is reinforced by an administration and infrastructure that supports clinical staff. Scott also respects that her homeless clients allow her to get involved in their story. "It's so important to realize that through their trauma," she says, "they allow people to rearrange, organize, and put things in order as they want them. They allow us to do our work as nurses."

Williams, whose career has focused on the at-risk urban poor, offers a favorite quote by Helen Keller to describe what she's witnessed over the years: "Although the world is full of suffering, it is very full of the overcoming of it." Ultimately, she says, she has been struck by the resilience of her clients. "We get to see people triumph over some very adverse circumstances."

Janet M. Cromer is a freelance writer and regular contributor to On Call. She received the Will Solimene Award for Excellence in Medical Communication for her On Call article "Drawing Out the Best in People" (September 2005).

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