Valley Healthcare for the Homeless
Program (VHHP)

Larry Kwan, MD
Michael Lipman

Preview
• Who are the homeless?
• What are their barriers to care?
• How can we help?

Homelessness:
A National Problem
• 2-3.5 million
individuals
experience
homelessness per
year
• Highest rate increase
in past 2 decades

Homelessness:
A Local Problem
• 20, 000 homeless
episodes in the
County per year
• 5200 clients per year
at Emergency
Housing Consortium

SCVMC

1999 Santa Clara County
Homeless Survey
•
•
•
•

65% male
60% between 30 and 49
40% families
40% newly homeless, 42% chronically
homeless

1999 Santa Clara County Homeless Survey. Burstein JS and Woodsmall LJ

Santa Clara County:
RACE OR ETHNICITY
Hispanic-American
Caucasian
African-American
Native American
Asian American

36%
35%
17%
4%
2%

1999 Santa Clara County Homeless Survey. Burstein JS and Woodsmall LJ

Santa Clara County:

PRECIPITANTS OF HOMELESSNESS
“Why are you homeless?”
•
•
•
•

Lost job
Lack of affordable housing
Not enough money
Drug/alcohol abuse

1999 Santa Clara County Homeless Survey. Burstein JS and Woodsmall LJ

Where did all these homeless
people come from?
• 1980’s: Emergence of mass homelessness
–
–
–
–
–

Largest recession since the Great Depression
Unemployment rate 10.8%
Deinstitutionalization of the mentally ill
Increased illicit drug use (advent of crack)
Decreasing amount of affordable low-cost
housing

Adjusted Odds Ratio for Death from All Causes According to Annual Household Income,
1972-1989

3.~

·0

!ilt

-t;;Ji

.0

2.

-

2.0

1.

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Isaacs, S. L. et al. N Engl J Med 2004;351:1137-1142

Average Age of Death for
Homeless
City

Age

San Francisco
Atlanta
Boston

41
44
47

MMWR 1987;36:297-9.. MMWR 1991;40:877-80. Hwang SW et al., Annals of Internal Medicine 1997;126:625-628.

Mortality Rate in the Homeless
Compared to the General Population
City

Rate

Philadelphia
New York
Boston

3.5 times
4 times
1.6-5.9 times

Hibbs JR et al., NEJM 1994; 331:304-309. Barrow SM et al., Am J Public Health 1999;89:529534. Hwang SW et al., Annals of Internal Medicine 1997;126:625-628

Causes of Death in Homeless Adults in
Boston
(Hwang SW et al., Ann Intern Med 1997; 126:625-628)

Ages

Cause of Death

18-24
25-44
45-64

Homicide
AIDS
Heart disease and cancer

Health Status:
“Multiplicity of Needs”
Higher prevalence of:
–
–
–
–
–
–

HIV, TB, Hepatitis C
Hypertension (2x)
Poor dental health (31x)
Tobacco
Alcohol problems(6-7x)
Severe, chronic mental illness

Barriers to Health Care
Patient

Health Care
System

Health Care
Provider

Barriers to Care:
Characteristics of Homeless Patients
•
•
•
•
•

Disaffiliation
Distrust and Disenchantment
Mobility
Ubiquity of Alcohol
Multiplicity of Needs

Breakey WR. Treating the Homeless, Alcohol Health & Research World, 1987.

Barriers to Care:
The Health Care System
•
•
•
•
•

Scheduling
Complicated intake and registration
Fragmented care
Cost of services
Location

Breakey WR. Treating the Homeless, Alcohol Health & Research World, 1987.
Means RH. Www.womanofmeans.org

Barriers to Care:
The Health Care System

704-0900

488-9919

334-1000

Barriers to Care:
The Health Care System
Mental Health

Drug and Alcohol

704-0900

488-9919

Valley Medical
334-1000

Barriers to Care:

The Health Care Provider
Stigma and Bias
“Why can’t he work at a fast food restaurant?
There are plenty of jobs there.”
“They are all alcoholics and drug addicts.”

Breakey WR. Treating the Homeless, Alcohol Health & Research World, 1987.
Means RH. Www.womanofmeans.org

Barriers to Health Care
Patient

Health Care
System

Health Care
Provider

Barriers to Care:

Utilization

• No regular source of care :
1

– Homeless 57%
– Housed Poor 24%
– General Population 18%

• Primary source of care is ED
• Homeless are admitted to the hospital 6 x more
often than general population
• Hospital stays 4 days longer than low income
patients
2

3

4

1.
2.
3.
4.

Burt, Interagency Council on Homelessness, 1999
Kushel et al., JAMA 2001
Winkleby MA, AJPH 1992
Salit et al., NEJM 1998

“Failure to deal with a social problem ‘upstream’
(lack of housing, education, health insurance,
substance abuse prevention) leads to added
costs for resources ‘downstream’
(police, prisons, hospital care).”
Paul Starr, 1998

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Health Policy and the Homeless
• 1980’s: Increased public awareness of
homelessness
• 1987 Stewart B. McKinney Homeless
Assistance Act –
– Federal dollars to support Health Care for the
Homeless Initiatives around U.S.
– FY1998 128 funded programs
– SCVHHS received grant funding in 2003

Health Policy and the Homeless
• EXPAND
– SCVHHS received grant funding in 2003

Valley Homeless Healthcare
Program
Mission Statement

“The Valley Homeless Healthcare Program seeks
to improve access to quality, compassionate
health care for homeless individuals and
families in Santa Clara County.”

VHHP
Multi-disciplinary Team
•
•
•
•
•
•
•

Physicians (includes a psychiatrist)
Nurse practitioner
Dentist and dental assistants
Nurse Coordinator and nursing staff
Social Worker
Financial Counselors
Community Worker

VHHP
Program Categories
•
•
•
•

Outreach Services
QA and System Feedback
Partners and Links
Education

VHHP
Outreach
VHHP

Mobile Units

EHC Shelter
Clinic

Puentes Clinic

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You are here

;

VHHP Sites

(To Gilroy)

VHHP
QA and System Feedback
• Homeless Healthcare Advisory Board
• Ambulatory Quality Consortium
• Homeless encounter tracking system

VHHP
QA and System Feedback

-

-

DEMOGRAPHIC UPDATE/ HOUSING STATUS
Today's Date: _ _/_ _/_ _

Patient's Name: _ __ __ _ _ _ _ _ _ _ _ _ _ __
Patient's Date of Birth: _ _/_ _/_ _
Address: _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ City _ _ _ _ _ __ _ Zip Code: _ _ __
Home Phone: L__) _ _- _ _ Cell Pho~e: L__) _ _- _ _
Insurance Changes:

Message Phone: L__) _ _-_

_

If yes, what are the changes: _ _ _ _ __ _ _ _ __ _ _ _ __

Type of address:
(includes renting an apartment or room)
to United States (less than 1 year)- Living with family or sponsors .
If temporary, mark another box below.
family/friends

Housing

Program with no outside permanent housing

bus, car, camping
_ _ _ _ _ __

VHHP
Partners
–
–
–
–

Gardner Family Health Network
Emergency Housing Consortium
New Directions
SCC Collaborative / Homeless Task
Force
– Public Health Needle Exchange Program
– DADS / Methadone clinic
– Gilroy Unified School District

VHHP
Education
• Didactics

– Noon Conferences
– Grand Rounds

• Rotation(s)
–
–
–
–

Residents
Nursing
Nurse practitioners
Social workers

VHHP
Referral System
Primary Care

ED/UC
VHHP

Hospital

Outreach

“Our business is not to change people but to
offer hope and options.”
Barbara McInnis
Boston Health Care for the Homeless