Presented byTechnical Assistance Collaborative, Inc.

April 23, 2009

Des Moines is developing a long range action plan for people who are

homeless.

Access to health, substance abuse, and mental health services is critical to

the success of permanent supportive housing and other strategies to end

and prevent homelessness.

There are three steps in the planning process:

1. Define essential elements of a good services system based on what people

actually need.

2. Use the above definition to identify and document gaps and problems in the

current service system

3. Develop strategies and action steps to close the gaps and move towards the

defined good services system. This includes definition of the roles,

responsibilities, and interrelationships among the components of the system,

and the access points to benefits and services.

2

Same as everyone else, but more serious because of health risks

of homelessness and inadequate access to care

Also more serious because of multiple and long-term disabilities

requiring multiple different interventions and supports

Health risks made more serious by:

– Poverty

– Substance abuse

– Mental illness – 25 year difference in life expectancy

– Trauma

– Exposure to bad weather – damp, cold, etc.

– Poor diet

– Systemic barriers to access to health, mental health and substance abuse care

3

People who are homeless need access to:

– Psychiatric treatment and mental health supports

– Substance abuse treatment and on-going supports

– primary health care (prevention, screening for risk factors,

assessment, wellness)

– Acute care (health emergencies, trauma care)

– specialty health care (OBGYN, Orthopedics, Endocrinology)

– Long term care for chronic health conditions (Diabetes, COPD)

– Rehabilitative care (PT, OT, etc.)

– May need community supports to facilitate access to and

utilization of any of the above

4

Crisis response and stabilization

Inpatient treatment

Outreach/engagement

Case management

Psychiatric evaluation and treatment

Medications

Outpatient counseling

Community supports – skill building

Peer supports – peer counseling

Employment supports

5

Crisis response and stabilization

Detoxification (social, non-medical, and medical)

Motivational interviewing and engagement

Intensive outpatient

Residential treatment

Opiate treatment – methadone

Other medications (Naltrexone)

Employment supports

Oxford house

Peer supports, AA, NA, etc.

6

Need different services and approaches for children,

youth, parents, single adults

Need competency in co-occurring conditions

Need competency in trauma

Need cultural/linguistic competence

Need services geared to difficult to reach people,

including those who are homeless (outreach and

engagement, mobile services, harm reduction, flexible

community supports, etc.)

Need immediate/timely access to services

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Primary Health Care – Health Care for Homeless

– Best source of primary and specialty health

– Provides screening, care coordination, follow up

– Could assist with access to benefits

Emergency Departments (MH and SA, as well as

general acute health conditions and trauma care)

– Iowa Lutheran

– Mercy

– Broadlawns

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MECCA

◦ OP, IOP

◦ Transitional housing

Center for Behavioral Health

◦ Opiate treatment

◦ Methadone

Bernie Lorenz Recovery House for Women

Powel Center

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Crisis team – 20/7/365 phone + limited mobile response

Broadlawns (inpatient, psychiatry, outpatient, psychiatric

emergency response)

Eyerly-Ball (psychiatry, outpatient)

Child Guidance Center (psychiatry, outpatient)

MH presence in jail

Assertive Community Treatment (Medicaid only)

Residential services

Case management – service management

Employment services

Skills building – community living supports

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Mental Health

◦ Medicaid – Magellan

Medicaid primary health and mental health are separate

State bills county non-federal share of many disability services

◦ Non-Medicaid – Polk County Health Services

No formal funding or administrative linkages to either primary health or

substance abuse

◦ DHS – MH block grant + assuming funding for mobile crisis

Substance abuse

◦ Separate funding and management system from Mental health and primary health

◦ Magellan manages funding for substance abuse, but not integrated with MH within

the Magellan contract

Few reliable mechanisms for transitioning youth to the adult system (PCHS

has team and services for small number of transitioning youth)

Potential disconnect at re-entry from jail/prison

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For mental health, wait list for uninsured (non-Medicaid) for any types of

services except crisis, outpatient, meds, and inpatient

Same for substance abuse – long waits, particularly for residential treatment

Services narrowly targeted – difficult to establish priority for people with DV or

other trauma, family adjustment issues, other mental health issues not related

to serious diagnoses, etc.

Hospital emergency departments are overwhelmed (and perhaps

unwelcoming…)

Some providers are not geared up to serve people who are homeless or who

have multiple disabilities – do not have applicable competencies

Some providers do not deliver mobile services – expect people to come to the

service site

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• Little housing – no foundation for care/treatment/follow-up

• Lack of benefits - uninsured (MA, SCHIP [HAWK-I], VA, etc.)

• Severely limited resources for MH and SA treatments and on-going services

• Few clear access points and “rules” for eligibility or priority for service access

• Poor communications between systems (foster care, juvenile justice, substance

abuse, mental health, etc.)

• Lack of transportation

• Prior bad experiences with system

• Service models and approaches that are not tailored to people who are

homeless

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Access to benefits – eligibility?

Access to primary and specialty health services?

Access to Substance Abuse services?

Access to Mental Health services?

Access to transitional services for youth?

Coordination of service access and follow-up

across multiple services and payer sources?

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Primary health?

Crisis response and stabilization?

Tenancy supports?

Substance abuse?

Mental Health?

Case Management and care coordination?

Peer supports?

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Health?

Substance abuse?

Mental health?

Housing supports?

Other community resources?

Mechanisms to facilitate and support to

access to multiple benefits and services?

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Engagement – harm reduction, motivational strategies

Mobile services

Assignment of medical/clinical home – lead agency

Cross system case management

Housing support teams

Defined priority access to limited resources

Interagency agreements and cross system protocols

Cross system competency building on co-occurring disabilities,

co-morbidity of medical conditions, trauma, cultural

competence, transitioning youth, etc.

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Single “front door” to multiple benefits and services: “no wrong door”

One stop and be defined as a set of functions that could be

implemented in several places, including shelters, rather than in a

single building or location (PCHS does this with designated access

points)

The functions might include: facilitation of multiple benefit eligibility

determinations; facilitation of access to service resources from

multiple agencies and funding sources; direct support for people going

through the application process; advocacy for priority status for access

to community services and other resources; etc.

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