Outreach: Taking healthcare to the homeless
In Springfield, Mercy Medical Center's Health Care for the Homeless program is taking healthcare where it's needed most: at shelters and on the street
Homelessness is historically associated with individuals living on the streets. But families are the fastest-growing segment of the homeless population, making up nearly 40 percent of that demographic nationwide, according to the National Center on Family Homelessness. In Massachusetts, that percentage is even higher. The Massachusetts Coalition for the Homeless reports that families—parents and children—make up 52 percent of the homeless population in the Bay State.
"When people hear about the homeless," says Kathleen Chaconas, RN, who works for Mercy Medical Center's Health Care for the Homeless (HCH) program, "they think about people they see on the streets that might look a little rough around the edges. When I think of the homeless, I think about all the families that are out there."
Providing health services at multiple sites
The HCH program, located in Western Massachusetts, follows a nursing model of healthcare. Among the 18-member Mercy Health Care for the Homeless staff are six RNs, four nurse practitioners, and three case managers who provide on-site care at 46 locations—shelters, soup kitchens, job placement sites, transitional programs—and on the street. Services—which include assessment, intervention, episodic care, referrals, follow-up appointments, and education—are delivered in three counties (Hampden, Franklin and Hampshire) across 1,800 square miles. For a small number of their clients, the program also provides primary care services.
- When people hear about the homeless, they think about people they see on the streets that might look a little rough around the edges. When I think of the homeless, I think about all the families that are out there.
- – Kathleen Chaconas, RN
Chaconas's clientele consists of adults and families. She works in Hampden County and covers approximately eight sites. "Some of the nurses specialize in families, some adults only, some both," she says. "We have a main clinic at Worthington Street Shelter in Springfield. We provide a lot of primary care there. It is a clinical setting, whereas the other sites I go to are more like shelters and soup kitchens."
A typical week sees Chaconas traveling throughout Hampden County. Every Monday, she works at several different family shelters, and on Tuesdays, she provides care at a transitional housing site. Wednesdays find her at the McKinney Homeless Adult Basic Education program, which is part of the Massachusetts Career Development Institute (MCDI). On Thursdays and Fridays, she works at the Worthington Street Shelter and also spends time one of those days at the MCDI Families First Program.
Helping homeless families focus on their health
"A lot of the programs I go to require TB testing, so I do a lot of screening for that," Chaconas says. "[It is necessary] because congregate living can be a breeding ground for the spread of TB. We test frequently and report any positive findings to the health department for possible treatment. A positive test does not necessarily mean a client has TB, only that they have been exposed to TB at some point in their life."
Prior to working with HCH, Chaconas worked in an ER for almost 16 years and at the now-closed Linkage Project, a former Providence Hospital program. "I came to Mercy with a lot of assessment skills. When I worked with Linkage Project, I worked with a lot of substance abusers and also women who had mental-health issues. All that rolled together [for this job]," she says. "Most of the time [at Mercy] you are by yourself, and you need to be able to assess if there is a problem and figure out what to do about it. A lot of it is problem-solving too." The nurses—along with HCH case managers—try to get homeless children enrolled in MassHealth and find them a primary care provider. In addition, staff nurses do a lot of education, developmental screening, immunization checks, and referrals.
One of the challenges of working with this population, Chaconas says, is convincing people who have so many issues in their lives to focus on their health. "A lot of times they are too busy with other things to worry about their health," she explains. "They worry about their children. They worry about where they are living—or if they are not living anywhere, about just being safe."
A diverse, changing population
Judith Mealey, RN, MS, ANP, is the clinical manager of the Mercy HCH program. She has been with HCH for 20 years and has been in her management position for almost 13 years. But that doesn't mean she pushes papers. In fact, Mealey, who has a background in home health care, went back to school for an advanced degree while working for the program because she saw a need for someone who could treat patients and prescribe on-site. "At the time, when we saw something as simple as an abscess tooth, we would have to call a doctor and tell them what we were seeing," she says.
Today, Mealy spends 50 percent of her time on direct care. "I didn't go to school to be an NP and sit in an office all day long," she says. "I provide care at our biggest shelter, the Worthington Street Shelter, one day a week. Then I cover a sober shelter in Westfield two sessions a week."
Providing direct care is the part of the job Mealey enjoys most. "I love working with people, with individuals, offering them options and helping them see other avenues they can go in their lives. Our patients have so many issues. Just sorting them all out and helping them prioritize [is a lot of work]. It is very rewarding to have the ability to treat people respectfully because so many of our clients have been devalued in the general medical system."
Mealey's clientele are adults. Many have substance-abuse histories while others have major mental-health issues. Some are dual diagnosed, which means they have both a major mental-health disorder and a substance-abuse problem. "The educational level runs the gamut from people who are illiterate to people who have college degrees," she says. "I have people who have been homeless because their lives fell out from under them and people who have been homeless for years. It is not a homogenous population by any means."
The homeless population served by HCH, according to Mealey, is about one-third Caucasian, one-third African American, and one-third Latino (mostly Puerto Rican). "Over the years, I have seen the population become younger," she says. "We used to see a lot of the older alcoholics who managed to keep their substance abuse under control and who worked most of their lives. It is a progressive disease, so they finally hit the point where family had enough of them and they lost their jobs and became homeless. Now the clientele is more difficult because you have young people in their 20s who have little education and absolutely no work history. It is much more an uphill battle to get them stabilized."
Being more than a conduit for the healthcare system
Setting people up with a primary service provider is only part of the battle. The other half is getting them to go see that provider. That's one reason the nurse practitioners don't cover family shelters. "We want to be careful not to overlap services," Mealy says, explaining that if an NP goes to the family shelters, it's too easy for people to say they aren't going to see an outside doctor or NP for their kids. "They all have benefits," Mealey says, "and hopefully they will not be homeless for too long. It is better to have a healthcare system in place for them that will be seamless. Then, once they leave the shelter, they won't have to find a new doctor."
Sometimes, according to Doreen Fadus, MEd, HCH is the primary care provider for adults who are covered by MassHealth. Fadus is executive director of community health for Mercy Medical Center. "We have a small patient base that fits that description," she says. "Sometimes people stay with us and don't jump quickly into another primary care setting. That's because they know the nurses and they have a relationship with them. It's a different type of care [we provide]. They maybe get frustrated with a doctor's office or community health center because they have to wait or they cannot get an appointment right away." She adds, "It is not as simple as being a conduit, meeting them once, and turning them over to a primary care provider." On average, Fadus says, the program sees each individual at least five times.
Some clients at the larger shelters have no insurance. So HCH becomes their primary provider by default, according to Mealy. "Or there may be a variety of reasons why they choose us for their primary provider," she adds. "They may just not be capable of following through at that point in their life, either because of substance abuse or mental-health issues or the transient nature of the way they are living. So we would be their primary provider. But our goal is always to get someone a medical home that they can stay with once they are no longer homeless."
HCH also provides episodic care at the larger shelters. The patients may have other providers, but, according to Mealey, their chaotic lifestyle and multiple problems make it so they don't get all their needs met or questions answered when they go for a visit. "They may come in [to us] because they are not quite sure how they are supposed to take their medication or they are having difficulties with something else," she says. "We kind of wind up doing some intervention with them as well and supporting the care they receive from their primary provider."
The need for a sense of boundaries
HCH has one nurse who does street outreach, often in conjunction with another local agency. That nurse usually has a case manager who goes with her. "They go down to the river, out to the street, and down to the soup kitchen," Mealey says. "If they have something that needs to be seen by an NP, they usually bring the person up to the big shelter to be seen or one of us can do outreach."
Not all people want to go to a shelter for care, though, and may not want to deal with an obvious medical issue. "One nurse had a gentleman who had a badly swollen leg for quite a while. He adamantly refused to go anywhere to be seen," Mealey says. "So one of our nurse practitioners met him at the soup kitchen. He didn't want anything that should have been done to him, but at least we were able to touch base with him. The nurse is continuing to try to build a rapport with him and hopefully we will be able to get a study of the leg done."
A background in ER care or home healthcare is helpful when working in this field. Having a clear sense of boundaries is also a must. "You need to have a good sense of someone's autonomy and where your job ends," Mealey says. "You need to know when you need to back off." Referring to the man who appeared to have a vascular problem in his leg, Mealey says, "If someone is refusing healthcare, they have the right to do that. You try to build rapport and trust, document that he is refusing [care], and then continue to follow up to try to encourage him to get care. That is all you can do."
Nurses also strive to meet the client's perceived needs. "Someone may come in and say, "I need a pair of socks," Mealey says. "He may have a gaping wound in his head, but until you give him the socks, you are not talking with him but at him. We do a good job listening to people. If we see an issue they are not addressing and that needs to be addressed, then we will gently start working toward that as well. But we respect the fact that they came in for their reason."
Nurses, both RNs and NPs, are a good fit for this type of program because they provide holistic care, according to Fadus. "They are not just attending to the presenting medical problem that comes in the door. We are very person-centered in our approach, so if someone comes in with a wound and that is what they want looked at, we will do that. We might also inquire about where they stayed last night or ask if they are looking for a job. We also may ask if they are looking for housing and find out what are some of the things contributing to their homelessness, whether it is alcohol, mental-health issues, or something else."
Nurses are trained to deal with the entire person. "It is the whole sense of attending to the patients' needs," Fadus says. "The irony that we sometimes deal with in Health Care for the Homeless is [the difference between] what the patients' needs are and what the medical issues are as assessed by the RN."
Mealey stresses that the nurses who work for HCH are very flexible. "I think that we are able to change on a dime. Some of the healthcare establishment is very slow to change anything." She points out that the care they provide at HCH is all outreach. "Even though it is challenging to be in different shelters because you have to abide by their rules, we are meeting people on their own territory. That means they are less threatened. And we get things done."
Susan Wessling is a freelance writer and editor in chief of International Figure Skating. She is a longtime contributor to On Call.
Editor's note: This is the third in an ongoing On Call series of articles examining the issues around healthcare and homelessness. The first article, "Envelopes of Care," about caring for homeless families in Boston, appeared in April. The second, "Moving with Boston Health Care Program," described the facilities and the work being done at the Barbara McInnis House and appeared in August. The final article in the series will focus on the Boston Health Care for the Homeless Street Team.