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Conference Explores Challenge of Coordinating Care for Homeless

One theme: Healthcare providers and housing agencies need to communicate, share data

Healthcare in New Jersey’s cities increasingly relies on coordinating care across different medical and social-service providers, but that model breaks down when it comes to one of the most vulnerable groups: the homeless.

These residents fall through the cracks for a variety of reasons. When they’re on the street, they’re almost impossible to find. They move from place to place when they have somewhere to live. And in some cases they’re tossed out of housing or shelters because of inappropriate behavior.

What that means is that housing agencies and healthcare providers need to share information on an as-needed basis. It’s a goal that’s rarely realized.

The problems are particularly clear for officials of the three largest care-coordination agencies, located in Newark, Trenton, and Camden. They described some of their challenges at a recent conference in Newark sponsored by PICO New Jersey, a nonprofit community organization supported by religious organizations.

“It’s important,” said Dr. Ruth Perry, executive director of the Trenton Health Team for housing and healthcare officials to share data. “We’re performing case management for individuals who are homeless and then housing professionals are also providing case management, but we’re not really talking to one another at the level that we need.”

Trenton’s problems are particularly telling: In 2011 alone, 300 homeless residents made 1,500 visits to the emergency departments of local hospitals. Theoretically, this situation is exactly what Trenton Health Team was created to address.

The team’s professionals coordinate care for people who rely on hospitals as their primary caregivers, scheduling follow-up visits with the appropriate doctors and clinics after patients have been released from the hospital.

But care coordination relies on being able to reach patients when needed, which can be impossible when their clients don’t have a home.

“We’re talking about trying to make changes in ER utilization, but more importantly to get them the medical and social services and the mental health services that they deserve,” Perry said. “We need our social-service agencies and we need the government and all that are involved to step up and join with us in a more robust way” to make that coordination possible.

Perry called on the healthcare activists and community organizers attending the PICO conference to “stir the pot” with political leaders.

“We can really improve the system,” Perry said. “Otherwise, we’ll be limited in all that we do.”

Perry cited the example of the state’s Homeless Management Information System, which is used by many counties to track where homeless residents are living (assuming that they have a place to live), as well as what housing is available for them While this information is kept confidential by housing agencies, Perry said they should be able to share some of it with healthcare providers.

“We need to liberate the data,” she said.

As examples of how the system isn’t working, Perry cited the case of two Trenton-area residents whose care has been difficult to coordinate.

One was a homeless military veteran who was entitled to care paid for by the U.S. Department of Veteran Affairs. However, Trenton Health Team staff struggled to have him show up at the right time for transportation to appointments at a veterans outpatient center in nearby Hamilton. He needed treatment for substance abuse and mental-health problems. Finally, he had a health crisis that prompted him being sent to a veterans hospital in Lyons, where he has been doing well, Perry said.

Another man, who is deaf and mute as well as homeless, was ejected from a skilled nursing facility for bad behavior, but Perry said the facility didn’t provide a staff member who knew sign language to communicate with him.

While the state provides services for residents with similar needs, the man remains ineligible because he doesn’t have a permanent place to live, she said. He’s also burned bridges among local housing providers. “He continues to live in a storage unit outside the city, but we want to get him housed,” Perry said.

Nadia Ali of the Camden Coalition of Healthcare Providers, another agency that coordinates care, said the organization’s most successful attempt to provide frequent hospital users with housing has been a program in which a nonprofit sponsored five housing vouchers.

“Outside of that, it’s been an extreme challenge to get folks into housing,” Ali said, noting that coalition staff have made many visits to help residents with the paperwork necessary to prove they’re eligible for housing assistance.

“There’s so much time that needs to be put into it,” Ali said, adding that the residents face many barriers, including a lack of “literacy” about both healthcare and financial issues.

Michael Anne Kyle, project director of the Greater Newark Healthcare Coalition, said the effect of housing problems on improving healthcare should receive attention outside of care providers.

“There needs to be a discussion above the level of the healthcare center on this,” Kyle said.

She said the incentives for housing shelters to keep certain Medicaid-eligible residents in shelters has led to a lack of coordination with healthcare providers, since the shelters can lose money when residents spend time in hospitals.

“So there is this perverse cycle where the shelters are incentivized not to cooperate with hospitals, or not to cooperate with healthcare providers, because they’re running a business,” Kyle said. These facilities also aren’t interested in taking in patients who need temporary shelter if they aren’t eligible for Medicaid payments, further complicating the issue.

Kyle noted another issue: substance abusers who are caught using drugs in public housing are kicked out.

“That creates sort of a vicious cycle,” she said.

Apart from the problems faced by the homeless, many city residents live in substandard private housing. But raising this concern with landlords can lead to the threat of rent increases, Kyle said.

“People are living with no electricity, a broken roof, mold, lead — all other types of environmental hazards,” Kyle said.

“I think there needs to be a larger discussion about how we’re all paying for this somehow,” even those who don’t see the problem linked to themselves, she said. “You know, on a social level, I think there are a lot of opportunities to do this way better.”

Camden resident Pamela Robb called on healthcare providers to make the case forcefully to city governments that healthcare and housing needs should both be taken into account when cities are considering redevelopment projects.

“We don’t hear about homeless shelters” being included in plans for redevelopment projects, said Robb, a member of Camden’s zoning board. Robb urged conference attendees: “You need to rally your community” to work to improve housing.

About the Trenton Health Team
Trenton Health Team (THT) is an alliance of the city’s major providers of healthcare services including Capital Health, St. Francis Medical Center, Henry J. Austin Health Center and the city’s Health Department. In collaboration with residents and the city’s active social services network, THT is developing an integrated healthcare delivery system to transform the city’s fragmented primary care system and restore health to the city. THT aims to make Trenton the healthiest city in the state. Support for the Trenton Health Team was provided in part by a grant from The Nicholson Foundation. For more information, visit