Lincoln Community Health Center’s Health Care for the Homeless Clinic in Durham focuses its wellness approach on a population that’s hard to serve.
By Brenda Porter-Rockwell
An entire, 360 degree approach. That’s how the health care practitioners at Lincoln Community Health Center’s Health Care for the Homeless Clinic say they want to treat every homeless person who comes through its doors.
The homeless clinic, located on the campus of Durham’s Urban Ministries, focuses on treating physical and psychological ailments and coordinating social services for people living on the streets or in shelters. The clinic also serves those who might be sleeping on a couch in an already crowded dwelling.
At a minimum, each patient sees a nurse, a medical provider and a social worker. From there, referrals for specialty care may be added.
Jones said the clinic staff strives for positive outcomes for every client. In a 12-month period ending in June, that number came to 2,897 homeless clients, of whom 691 were first-timers.
“We’re working on all the little pieces of the puzzle for a better outcome,” explained clinic manager Quincy Jones.
Better outcomes for patients can be seen throughout the clinic’s most recent history. According to Jones, over the last three years the clinic has helped 35 people who were previously homeless secure permanent housing; another 25 have secured financial assistance to help with housing, medications or transportation; and another 35 have received Social Security disability benefits. Applications for each of these services can take a community health worker days to complete.
And Jones said they’re seeing a decrease in emergency room visits among clinic patients.
“We know this is a particularly vulnerable population. The medical problems don’t exist alone. You have to look at the social issues and the psychiatric issues as part of the bigger picture for that patient,” said Jones, pointing out that these smaller, individual services result in a lower cost to the larger medical system.
For example, a homeless man came to the clinic recently with a history of living on the streets rather than in shelters. Jones said the man was addicted to alcohol and suffered from chronic pain from his former work in construction and other manual labor.
After treating the man for his pain, Jones referred him to Duke Orthopaedics for outpatient care. She also introduced him to the clinic’s social worker, who began work on his Social Security disability application.
Finally, Jones pointed the man to the staff substance-abuse counselor, who will continue to follow the man’s progress in dealing with his addiction.
“So he’s gotten his medical needs addressed, he’s gotten specialty care, we’re working on the substance-abuse issues, and we have a social worker working toward getting him connected with disability,” she said. “If that [application] is successful and he has an income, that might enable him to get housing.”
The Lincoln Center’s clinic is “really vital to the community,” said Lloyd Schmeidler, who has been involved with the homeless population for the last 15 years as project manager with the City of Durham’s Community Development Department.
“Their work is indispensable,” he said.
The Homeless Clinic began in 1988 as a small outreach operation funded by a federal Health Resources and Services Administration grant.
At that time, services consisted of a doctor making biweekly evening visits to the Urban Ministries shelter to accommodate the male tenants who worked days. Behavioral health services included consultations with mental health professionals. Seven years later, the clinic added daytime hours to increase access to care for women and children.
Today the clinic’s medical staff sees patients five afternoons a week, while the social services and behavioral health teams see patients weekdays during business hours.
The extended hours are necessary. As of the end of January, the homeless population in the City of Durham/Durham County totaled just under 1,000 persons, according to the Point in Time count published in this year’s Continuum of Care report, which tracks the homeless population in return for federal funding to support various homelessness programs.
According to the report, a significant portion of the homeless population is single, childless adults over age 18 living in emergency or transitional housing. Less than 10 percent of the total population was described as chronically homeless, meaning people with a disability and who were homeless for at least one year or have had four episodes of homelessness in three years.
“The health care challenges they take on are really enormous,” said Schmeidler, who is also former executive director of Urban Ministries and coordinator of the Continuum of Care count.
“Part of the focus in long-term homelessness is that it has such negative consequences on physical, emotional and mental health,” he said. “So much so that many doctors are now talking about how housing has therapeutic value.”
Lincoln is not alone in its mission to help the homeless, but its approach is the only one of its kind in the county. Samaritan Health Center, also in Durham, provides comprehensive medical and dental care to the homeless and underserved populations, whereas Lincoln’s clinic focuses strictly on the homeless.
The distinction is important, advocates say.
“Health centers designed to specifically serve people experiencing homelessness are needed because these individuals are not getting their needs met elsewhere and … they encounter many barriers to care.” said Molly Meinbresse, a researcher at the National Health Care for the Homeless Council.
The Continuum of Care report found there were 153 homeless people experiencing a mental illness, another 238 were dealing with substance-abuse issues and nine people had been diagnosed with HIV/AIDs.
Common chronic medical issues include diabetes and high blood pressure.
“When we manage these things in the homeless population, we have to think about additional factors in treating these problems,” Jones said, “such as: Will the patient have a place to store his or her medication? If we are giving them a diuretic, will the patient have access to a bathroom?”
When discussing dietary issues such as reducing sugar, carbs or salt for various problems, Jones said practitioners have to think about how much control patients actually have over their diet since many may only be able to eat what is available at the shelters or from food pantries.
As part of what Meinbresse calls “enabling services,” the Durham clinic sees many patients experiencing psychiatric disorders, including depression, anxiety, post-traumatic stress disorder and substance abuse. At the other end of the psychiatric spectrum, some patients arrive at the clinic already experiencing severe psychotic episodes like visual or audible hallucinations.
“That would be a totally different kind of case, where we make an emergency connection with a crisis facility in Durham so they can be transported … and stabilized with medication,” Jones said. “They can then come back to us once they’re more stable. From there, we can piece out what we need to work on – is it medical, is it social, is it psychiatric?”
For those patients needing behavioral health support or help with substance-abuse issues that the clinic can’t handle due to limited resources, they refer them to the main Urban Ministries campus or other community-based specialty providers.
The homeless clinic also helps streamline testing procedures by referring patients to onsite pathology and radiology labs and a pharmacy on the main health center campus.
“We’ll see someone at our Durham clinic and we can send them over to our [main] facility for x-rays or lab work,” said Jones. “I think that makes us particularly unique. Those are very hard services to coordinate with outside agencies.”
In addition to the social worker and the substance-abuse specialists, the clinic also has a community health worker who assists those who have had four or more emergency room visits in the last two years.
The social worker tracks that population subset to ensure they stay connected to primary or specialty care in an effort to decrease the number of visits by the homeless to emergency rooms.
This type of assistance becomes important, noted Meinbresse, because local hospitals and urgent care centers may not be equipped to handle the specialized needs of the homeless.
“Health care for the homeless health centers excel in providing integrated health care services and encouraging staff to practice cultural humility and trauma-informed care,” said Meinbresse.
Paying for care
The clinic technically does not offer free services, but no one is turned away because of an inability to pay.
“If you’re homeless and come through those doors, we’ll help you,” said Jones.
The clinic is still supported by Health Resources and Services Administration funding as well as grant money from the National Health Care for the Homeless Council, which supports the community health worker position. The center had been receiving some state funding from the Department of Health of Human Services, but that ended at the close of last year.
“We want all individuals, including people who are homeless, to have a primary care health home,” said Meinbresse, “so that there is good care coordination and continuity, preventive services can be provided in a timely manner and chronic conditions can be monitored by the same providers.”