Health Care for the Homeless: A Vision of Health for All

Background and Purpose

The overall purpose of this report is to reconstruct the history of the Health Care for the Homeless (HCH) movement in order to understand where the movement came from and how it developed; to assess its strengths and challenges; to discuss its future within the contemporary U.S. health care landscape; and to offer recommendations for moving forward.

The focus is on the historical roots of the National Health Care for the Homeless Program and the National Health Care for the Homeless Council (NHCHC), as represented through the oral histories of long-time workers (Pioneers) of the program, as well as through various written summaries and reports.

HCH began as a national demonstration program of the Robert Wood Johnson (RWJ) Foundation and the Pew Memorial Trust in 1985, was replicated and expanded in the 1987 McKinney Act, and, as of the most recently available data (2015), serves over 890,000 people experiencing homelessness each year through 295 federally-funded health centers. Through the Health Center Consolidation Act of 1996, HCH became part of a larger set of programs addressing access to care through a network of safety-net, community-directed care providers.

Over the past three decades, the National HCH Council has successfully gathered the interests of health care professionals, researchers, advocates, and people without homes into a respected, coherent, and principled movement that insists upon quality care and the human right to housing and health care. Little documentation of this remarkable health care justice movement exists.

Many of the long-time leaders of HCH are retiring and transitioning to other endeavors, and these Pioneers seek a means to gather for future leaders their collective experience and insights, even as the health care environment changes rapidly and new homelessness and health care interventions emerge.

Methods

In conjunction with the annual National Health Care for the Homeless Conference and Policy Symposium held in Portland, Oregon, from May 31-June 3, 2016, the National HCH Council and conference organizers planned a special four-hour session, “HCH Pioneers Explore the Past and Address the Future of HCH.” This conference session was planned as an interactive session with consecutive panels of long-time leaders in HCH discussing the following:

1. The vision and values of the HCH movement with its balanced commitments to direct service, policy advocacy, consumer involvement, and ending homelessness.
2. The evolution and development of the HCH model of health care, including what factors contributed to the changes, and how the HCH model fits within the current health care environment.
3. The impact of HCH in terms of improved health of the homeless population, influence on other social justice movements, and influence on the U.S. health care system.
4. Ongoing and future work of HCH, such as the changing role of HCH. within the rapidly evolving health care environment, the work of HCH to end and prevent homelessness, and the mandate for HCH leaders moving forward.

Leading up to the HCH Pioneers session, John Lozier, executive director of the National HCH Council, drafted a historical timeline of the HCH movement with dates of key events, people, reports, and federal legislation affecting HCH. This timeline was circulated to the long-time HCH leaders ahead of the Pioneers Session for people to make additions, and then copies of the amended timeline were circulated at the tables at the session for participants to review and amend.

Between the panel presentations, two table discussions and large-group feedback time periods were scheduled, with each table having an HCH Pioneer long-time leader as the small group facilitator. Forms were provided at each table for participants to record their thoughts on each of the four session content discussion areas, and people were asked to include their names, phone, and e-mail addresses for possible follow-up clarification or elaboration of their notes.

Due to time constraints, with panelists exceeding their scheduled time allotments, only one of the table discussions was accomplished. Out of a total of 140 session participants and 12 tables, we received a total of eight completed forms, two of which were from table discussion summaries. One of the individual forms was from a person who read his responses to the group during the large-group feedback time; therefore, it was duplicative information.

The Pioneers Session was audio-recorded, with panelists and the people using the microphone during the large group feedback captured on the recording. The Pioneers Session assigned Recorder, Josephine Ensign, took hand-written notes during the session, focusing on recording nonverbal cues of the speakers and audience members during the session, as well as other observations in order to add contextual information to the audio-recording and participant written forms.

After the Pioneers Session, Ensign listened to the audio-recording of the session, read the participant forms, and wrote expanded field notes of the session. Drafts of these expanded field notes were shared with John Lozier and Barbara DiPietro, who directs the policy and advocacy activities for the National HCH Council, for their changes and additions.

Overview of Findings

The HCH movement did not develop within a vacuum, but rather grew out of other social justice and health care movements in the U.S. in the 1960s and 1970s. HCH has direct ties with the organizers and policy makers involved in the Community Health Center (CHC) movement. Key figures in the CHC movement were directly influenced by the World Health Organization’s community-based primary care model.

Therefore, a deep understanding of the historical roots and trajectory of CHC is essential for reconstructing the history of HCH. Teasing out the impediments and differences between the mission, values, and activities of HCH vis-à-vis CHC programs would be a fruitful future endeavor. These challenges were highlighted throughout the Pioneers Session by various long-time workers in the HCH movement. Representative statements for this include:

• “When we became a Federally Qualified Health Center (FQHC) and CHC, we had a big job of convincing our staff we hadn’t lost our mission,”
• “There’s little recognition of HCH within—we don’t always look like our brothers and sisters within the community health world.”

It is interesting to note that the roots of the CHC movement were mainly within a Southern rural, impoverished community that lacked any organized health care services, while the roots of HCH were within a large metropolitan, mission-focused hospital system. Also, the CHC movement has garnered considerable bipartisan support over the past 20 years, while subpopulation-focused programs like HCH have also grown, but mainly from being folded into the CHC funding stream.

There was considerable discussion of the role of HCH within the rapidly changing U.S. health care system. Pioneers pointed out that there was a growing chasm of opportunity and experience between HCH programs in Medicaid expansion states versus those in non-Medicaid expansion states. Many speakers highlighted key aspects of HCH that have now been adopted by the larger health care system:

1. Team-based care models.
2. Provision of comprehensive, wrap-around health services.
3. Development of medical respite.
4. Outreach programs aimed at reducing unnecessary ED visits and hospitalizations.
5. Emphasis on the message that housing is health care.
6. Patient-centered medical homes.
7. Inclusion of motivational interviewing and trauma-informed care.

One speaker pointed to relatively recent published studies opining that, “evidence of eliminating HCH services … didn’t make a difference [to federal supporters] … Doing the good work that you do is 100% optional, and I don’t think that should be our future.”

Another long-time HCH worker and health policy researcher stated, “The challenge is how the HCH model should be changed to fit the new system with its emphasis on health care outcomes, of proving that what we do makes a difference.”

He followed this with, “We’re in a position of saying, ‘Well, what are the outcomes that are appropriate for this population?’” And he advocated for the inclusion of housing, employment, and social services, “things that aren’t getting discussed very much when we talk about outcomes in health care.”

Points of difference that emerged in the Pioneers Session had to do with whether or not ending homelessness was an explicit goal of the HCH movement from the beginning.

Several of the speakers from the original RWJ-Pew HCH demonstration program spoke of being dismayed that 30 years later they still have a job and that the U.S. still has the problem of homelessness. Other speakers responded to this by pointing out that the original RWJ-Pew HCH Program mandate was to help change the overall health care system so that it would be more responsive to the needs of vulnerable populations, including those experiencing homelessness—and that while HCH has done a good job with that, there is still considerable work to be done.

Related to this was a thread throughout the discussion of the role of HCH in continuing to advocate for a single-payer health care system, with Pioneers pointing to the fact that such a health care justice perspective had been an original part of the HCH mission and policy work.

Recommendations

• One of the main recommendations is for the HCH Council to establish an improved and sustainable internal system for tracking and documenting the history of the HCH movement. One possibility is to partner with CHroniCles: The Community Health Center Story, a multi-media website of historical documents, photographs, videotaped oral histories, and written histories related to the Community Health Center movement, which is inclusive of Community, Migrant, Homeless, and Public Housing Health Centers (http://www.chcchronicles.org). This website is a special project of the RCHN Community Health Foundation, the Geiger Gibson Program in Community Health Policy at the Milken Institute School of Public Health and Health Services at The George Washington University, and the National Association of Community Health Centers. It is dedicated to highlighting and recording the contributions made by community health centers across the country in delivering high-quality and comprehensive primary health care services. The site showcases contributed narratives, photographs, data, and other materials to advance an understanding and awareness of the vital role that community health centers play in the American health care system. CHroniCles celebrates the distinctive history of the health center movement, and the significant role community health centers fulfill in the lives of millions across the country. By contributing to this site, the National HCH Council would also add the unique history and perspective of the HCH movement within this “living history” website.
• With HCH membership growing and broadening to become inclusive of a CHC focus, dilution of the vision and mission and the sense of community the National HCH Council helped nurture is a potential unintended outcome. Therefore, part of the essential work of the National HCH Council is to find ways to address this threat, looking towards models of doing this well in terms of scaling up while maintaining the mission focus.
• The National HCH Council should consider finding the resources in order to conduct a meaningful, cost-effective, and anonymous survey of NHCHC members to find out additional important information, such as political leanings, whether or not people living in non-Medicaid expansion states are feeling alienated from the work of the Council, and what members find most valuable—as well as what is missing—from the work of the National HCH Council and the overall HCH movement.
• Besides the HCH Pioneers Session and this history report, which is meant as an internal document for the National HCH Council and its members, additional ways should be explored to share key findings more broadly. For instance, in terms of increasing the possibility for the HCH movement and Council to influence the future trajectory of the U.S. health care system, scholarly articles could be written for key health policy journals such as Health Affairs.
• While the HCH Pioneers Session and the work of gathering and synthesizing additional historical documents in the report are important steps, the National HCH Council should heed the advice of one of the Pioneers Session speakers who recommends a retreat in order to ask a “compendium of questions … to ask ourselves the hard questions of what we aren’t doing well, where we need to change.” Finding a way to have these critical conversations, inclusive of not only the long-time Pioneers of the HCH movement, but also of newer members and those who have opposing ideological viewpoints, is essential for the healthy future of the HCH movement.
• In addition, there is a need for a larger-scale, more comprehensive research-based report on the history, development, impact, and potential future for the HCH program. In order to avoid potential or perceived bias, such a report would best originate from outside the NHCHC. Perhaps the Institute of Medicine would consider a report in follow-up to their 1988 report Homelessness, Health, and Human Needs.[1][2]

     [1] Institute of Medicine (U. S.). Committee on Health Care for Homeless People, Homelessness, Health, and Human Needs (Washington, D.C.: National Academy Press, 1988).

     [2] As of Summer 2016, the National Academies of Sciences, Engineering, and Medicine’s Science and Technology for Sustainability (STS) Program and the Board on Population and Public Health Practice are beginning a new study on “Housing, Health, and Homelessness: Evaluating the Evidence.” The study will evaluate interventions and policy options for addressing urban homelessness, particularly permanent supportive housing programs. Specifically, the study will address the fundamental question: to what extent have permanent supportive housing programs improved health outcomes and affected health care costs in people experiencing homelessness?  To address this question, the committee will take into consideration any variation in outcomes for different subsets of homeless populations, including people experiencing chronic homelessness and people identified as high-utilizers of health care services, as well as the variation in outcomes related to different housing configurations and approaches to service delivery and financing associated with permanent supportive housing.