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Service Delivery Innovation Profile

Shelter-Based Medical Care and Case Management Enhance Access to Services for Homeless Women, Improve Outcomes, and Lower Costs


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Snapshot

Summary

The Women of Means program makes barrier-free, personalized health care and case management services available to homeless women in the Boston area, with specialized, more intensive services for the long-term homeless over the age of 55. Volunteer clinicians visit shelters regularly to provide preventive care, basic medical and hygiene supplies, and routine diagnostic testing. Paid nurses accompany the clinicians and provide case management services that connect women to other needed medical and social services in the area, including housing. Program staff and volunteers also provide training to other medical professionals and students in the area about effective care for the homeless. The program has enhanced access to medical and social services for thousands of homeless women, improved health outcomes for women over 55 with diabetes and hypertension, and saved an estimated $2 to $3 million per year by reducing the need for expensive inpatient and emergency department care.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on the number of clinical encounters and women served (both overall and for a special part of the program serving women over 55), along with pre- and post-implementation comparisons of select outcomes for women over 55 and staff estimates of program-generated cost savings.
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Developing Organizations

Women of Means, Inc.
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Date First Implemented

1999
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Patient Population

Gender > Female; Vulnerable Populations > Homeless; Womenend pp

Problem Addressed

Homeless women make up an increasing proportion of the homeless population in many cities, and face a variety of health problems due to their unstable living situation, increased risk of abuse, and other poverty-related challenges. They often do not feel comfortable or safe seeking care in specialized clinics set up for the homeless. As a result, they frequently forgo care, leading to missed diagnoses, uncontrolled chronic conditions, and increased risk of death.
  • Growing numbers of homeless women: Women and children make up the fastest growing segment of the homeless population. In Boston, an estimated 2,100 women are homeless, accounting for nearly one-third of the homeless population. Many of these women also have their children with them.1
  • More health problems than men: Homeless women face more health problems and issues than do homeless men, stemming from their living situation, past abuse, and biology. For example, housing insecurity increases a woman’s risk for serious health problems due to stress, poor nutrition, exposure to extremes of weather and communicable diseases, and other factors.2 In addition, women need reproductive care, and hence should see providers more often than men. Finally, homeless women face an increased risk of abuse, which often leads to physical and mental illness, injury, and trauma. An estimated 35 to 50 percent of homeless women and children are victims of abuse nationally. In Massachusetts, 92 percent of homeless women have experienced physical or sexual assault.3
  • Multiple barriers to care: Homelessness makes seeking care and following up on treatment recommendations difficult. In one survey, more than one-third of homeless women reported that they have not received needed care in the last 2 months.4 Multiple factors account for this lack of access, including the following:
    • Other priorities: The demands of life on the street often take precedence over seeking care for medical or psychiatric illness.
    • Shame: Women are more likely than men to be homeless for economic reasons (rather than substance abuse or mental illness), and consequently they may feel ashamed of their situation and hence may be more reluctant to seek help.
    • Lack of comfort, safety: Homeless women often do not feel comfortable seeking care in the same place as homeless men, who may subject them to violence, trauma, and harassment (especially if there is a long wait for care). For example, homeless women who seek treatment for pain-related issues report being afraid of assault and robbery after a medical visit.2,5
    • Lack of culturally sensitive care: Many clinicians and practice staff have limited experience with homeless patients, resulting in an insensitive and unwelcoming reception and even more obstacles to navigate when women do seek care. Consequently, many homeless women choose to visit community health centers and not reveal their homeless status. As a result, physicians do not have the full picture of their circumstances and may give instructions that prove unrealistic for someone who is homeless.5
  • Leading to poor health outcomes: Years of missed primary care, mammograms, and contraceptive and prenatal care often lead to a variety of health problems for homeless women. For example, homeless women have twice the rate of pregnancy and face a higher risk of sexually transmitted diseases (STDs) and human immunodeficiency virus than do women in the general population. In addition, the average homeless women has eight to nine concurrent medical illnesses, and the typical homeless women in her 50s experiences chronic disease at a rate similar to women 70 and older in the general population. Overall, homeless women face a dramatically greater risk of dying (5 to 31 times) than does the average woman.6
  • Medical Home Without Walls: Information provided in June 2013 indicates that a new pilot program that integrates primary care and care coordination was launched to deliver care to elderly homeless women through an established clinical team that works in the community.

What They Did

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Description of the Innovative Activity

The Women of Means program makes barrier-free, personalized health care and case management services available to homeless women in the Boston area, with specialized, more intensive services for the long-term homeless over the age of 55. Volunteer clinicians visit shelters regularly to provide preventive care, basic medical and hygiene supplies, and routine diagnostic testing. Paid nurses support the clinicians and provide case management services that connect the women to available medical and social services in the area, including housing. Program staff and volunteers also provide training to other medical professionals and students in the area about effective care for the homeless. Key program elements include:
  • Regularly scheduled free clinics at shelters: Volunteer clinicians from a range of specialties (internal medicine, psychiatry, pediatrics, obstetrics/gynecology, dermatology, emergency medicine, and family medicine) conduct shelter-based clinics each week, with clinics timed to coincide with periods when vulnerable women and children tend to congregate at the shelter. The program offers two to four clinics each week at two local women’s shelters, along with regular clinics at five other shelters. Many women in the program do not maintain a relationship with a primary care provider, so Women of Means becomes their de facto primary care provider.
  • Barrier-free services with "personal" touch: Any homeless women can receive services by signing up care on a clipboard set out at the shelter. They do not have to use their real name or present any identification, and there are no eligibility requirements. (As a private nonprofit organization not bound by reimbursement issues, Women of Means can provide care without bureaucratic barriers.) All services emphasize a "personal touch" designed to build trust with the patient. For example, although the program maintains an electronic medical record (EMR) system, clinicians do not take laptops or even file folders into the examination room. Instead, they jot down a few notes on a folded piece of paper, keeping their focus on the patient. Many homeless patients remain suspicious of technology and records, so this approach helps avoid that barrier. (Clinicians fill out the EMR on computers at the program office after finishing at the shelter.) Available medical services include the following:
    • Medical examinations (with no time limits): Clinicians spend as much time as needed to assess the patient’s presenting problem(s) and other issues. The clinicians use the examination as a way to build trust with the patient, with the goal of making access to health care and other services seem easier in the future. Especially with older patients, clinicians assess whether they have dental, mental health, and/or vision issues.
    • Free medical and hygiene supplies: As needed, clinicians and staff provide free medical and hygiene supplies, such as antibiotic cream, lotions, and clean socks. These supplies not only address immediate needs, but also help to build trust and a sense of caring.
    • On-the-spot diagnostic testing: Clinicians can run routine diagnostic tests, including for strep throat, pregnancy, and STDs. Offering these tests onsite serves to eliminate a potential barrier to diagnosis and followup care.
  • Case management by nurses: Paid nurse case managers support the volunteer clinicians by working with patients to identify and address barriers to their receiving more consistent health care, stable housing, and other social services. Boston has a wealth of resources available, but homeless women often cannot access them. The case managers help link them to these resources and keep them connected over time. Nearly half of clinical encounters involve some case management, including the following:
    • Facilitated connections to primary and specialty care: Women of Means has developed relationships with more than 500 primary care and specialty physicians who will treat homeless patients. Program staff help with transportation and even will escort patients to appointments. Escorts help the women overcome their fear of disrespectful treatment and stigma when seeking care.
    • Assistance applying for benefits: Most women in the program qualify for government assistance (e.g., Medicare and/or Medicaid), but find it difficult to apply for (and remain enrolled in) such programs, especially without stable contact information. In some cases, Women of Means furnishes cell phones so that women can provide contact information and better manage their own social and medical service appointments.
    • Connections with other health services: Staff have developed relationships with other programs that provide eyeglasses, dental care, and other needed health-related services to homeless women.
    • Assistance with housing and transitions: To qualify for many housing programs, applicants must prove they are medically stable. Doing so can be difficult for homeless individuals, particularly those with existing mental health or substance abuse issues. To address this issue, clinicians help patients manage their health conditions so as to meet the requirements set by housing programs. Staff also help fill out the requisite forms and aid in the transition to stable housing (because women may find it lonely and isolating having their own place after living on the streets or in shelters). Many women continue to seek health care through Women of Means even after they secure stable housing.
    • Followup monitoring: Nurse case managers attempt to contact every patient at least once a quarter, either by phone or in person (although it can often be difficult to track patients down). When they make contact, staff inquire about ongoing treatment and other needs, including whether the woman remains in contact with her primary care physician. This followup continues after women have accessed stable housing.
    • Intensive case management for older women: Launched in May 2010, the Aging in Shelter Collaborative provides more intensive case management and followup services to homeless women over age 55. Through collaborations with other agencies, the program seeks to address the needs of these long-term homeless women, who have even higher rates of chronic illness, neurological and psychiatric illness, history of abuse, and lack of executive function.
  • Training for medical professionals and students: Program staff and volunteers provide hands-on training about appropriate care and treatment of homeless patients in general (and women in particular) to more than 100 medical and nursing students from local colleges and universities. Staff and volunteers have also written a book about medical care for homeless women.
  • In-shelter education and exercise classes: Through relationships with area health and wellness providers, the program organizes health-related workshops, exercise classes, and other events in homeless shelters, with the goal of increasing women's knowledge and opportunities related to healthy living.

Context of the Innovation

Roseanna Means, MD, established Women of Means after 20 years as a primary care physician. During her residency, she worked for an international relief organization, providing care to Cambodian refugees in Thailand. In this setting, physicians provided quality care to displaced people with "no strings attached." Although she could not immediately put this approach into practice when she returned to Boston, the idea took root that she would like to practice medicine in this way for disenfranchised patients closer to home.

During her several years working for Boston Healthcare for the Homeless, she noticed that only a small portion of the city's homeless women sought care. Her investigation of this issue identified stigma, fear of violence, logistics of childcare, and the pressures of life on the street as major factors preventing women from getting care. She developed Women of Means as a way to address these challenges by using the model she saw work effectively in Thailand.

Did It Work?

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Results

The program has enhanced access to medical and social services for thousands of homeless women, improved health outcomes for women over 55 with diabetes and hypertension, and saved an estimated $2 to $3 million per year by reducing the need for expensive inpatient and emergency department (ED) care.
  • Enhanced access for vast majority of area's homeless women: Since its start in 1999, Women of Means has completed 85,000 clinical encounters (roughly 10,000 per year), providing the vast majority of homeless women (and their children) in the Boston area with services that otherwise would have been difficult if not impossible for these women to access. The program currently serves more than 90 percent of the city's homeless women (2,000 out of the estimated 2,132 homeless women in the area).1,5
  • Enhanced access, better outcomes for aging homeless women: As of the end of 2010, more than 100 patients had been enrolled in The Aging in Shelter Collaborative for homeless women over age 55. Preliminary data from the first few months suggest the program has enhanced access and improved health outcomes, as outlined below:
    • Enhanced access: Forty percent of enrollees with chronic illness had two primary care visits within the 7 months of the program; 10 women received cell phones that allow them to connect to their primary care physicians directly; 3 women receive regular psychiatric counseling; and case managers have made more than 100 inquiries to secure more stable housing for clients.7
    • Better outcomes: Among the 12 women diagnosed with diabetes, mean blood glucose levels have fallen from 198 at enrollment to 168 a few months later. Among the 27 women with hypertension, average blood pressure fell from 134/88 mm Hg to 128/78 mm Hg.
  • Significant (estimated) cost savings: Program staff estimate that the services provided by clinicians and case managers save $2 to $3 million each year by preventing the need for expensive inpatient and ED care.5

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on the number of clinical encounters and women served (both overall and for a special part of the program serving women over 55), along with pre- and post-implementation comparisons of select outcomes for women over 55 and staff estimates of program-generated cost savings.

How They Did It

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Planning and Development Process

Key steps included the following:

  • Securing initial grant: After leaving Boston Healthcare for the Homeless, Dr. Means approached her church and received a small grant to start a program to address the health care needs of homeless women in the Boston area. With the money, she established a small office in her home, created letterhead and brochures, and started visiting homeless shelters once a week. As a familiar face, she could effectively talk to women about their health care needs and find out what prevented them from seeking care and what could help them access care more easily.
  • Launch of early version of program: Based on the feedback she received, Dr. Means put together the elements of a model that offered both immediate care and also connected patients to the larger health care and social services system. She started by visiting shelters once a week with a clipboard and stethoscope. If women needed medication or supplies, Dr. Means would purchase them.
  • Expansion to offer diagnostic testing: Although an examination and over-the-counter medication and supplies helped many women, others needed diagnostic tests (e.g., strep tests, pregnancy tests, urinalysis), which were only available at a special clinic for the homeless that many women did not like (and hence avoided). To address this barrier, Dr. Means procured a Clinical Laboratory Improvement Amendments waiver through the state to cover the cost of these tests. She also secured a separate grant to fund asthma nebulizers to be distributed to patients with asthma.
  • Building connections to primary care: Although some women had a primary care physician, most had no link to the larger health care system. Through her connections with community health centers and other primary care physicians willing to see homeless patients, Dr. Means set up a network of clinicians to whom she could refer patients for ongoing care.
  • Incorporation as nonprofit organization: After a year of seeing patients on a small scale and further enhancing the approach, Dr. Means incorporated Women of Means as a nonprofit 501(c)(3) organization, which allowed her to expand services to more homeless women.

Resources Used and Skills Needed

  • Staffing: In 2012, the program employed 7 part-time nurses, an executive director, a part-time grant writer, a director of operations, an office manager, and a part-time medical director.
  • Costs: In 2012, the program budget totaled $706,020, which covered employee salaries, office space, and other administrative expenses. In 2013, the budget will be $735,600. 
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Funding Sources

Josiah Macy, Jr. Foundation; Robert Wood Johnson Foundation; Blue Cross Blue Shield of Massachusetts Foundation; Yawkey Foundation; State Street Foundation; Partners HealthCare System; Clipper Ship Foundation; Citizens Bank Foundation; Bank of America Philanthropic Management; Campbell and Hall; CVS/Caremark Charitable Trust; Covidien; Boston Scientific; Liberty Mutual Foundation; Massachusetts Medical Society; SWAN Society; George and Alice Rich Charitable Foundation; Horncrest Foundation; Bank New York Mellon; Eastern Bank; Little Family Foundation; Llewelyn Foundation; Massachusetts Women's Home; Old South Church; Rockland Trust; Ward Foundation; Tufts Heath Plan Foundation
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Tools and Other Resources

Staff and volunteer clinicians have written a curriculum for medical professionals who do not have experience working with the homeless. Entitled Medical Care of Homeless Women: A Curriculum for Novice Providers, this curriculum can be purchased through Women of Means by telephone (781/239-0290), fax (781/235-6819), or e-mail (info@womenofmeans.org).

Adoption Considerations

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Getting Started with This Innovation

  • Listen to target population: Time spent gathering information and ideas from homeless women helped Dr. Means design a program that truly lifted the barriers to care. It also helped build trusting relationships with the women she sought to serve.
  • Build on previous relationships: From her previous positions, Dr. Means was well known in the homeless and medical communities. She built on these relationships to gain trust in both communities.
  • Start small: For the first few years, the program offered onsite clinics at only 2 shelters, building up to 5 shelters in the third year and reaching a high of 12 shelters in 2005 (year 6). Several shelters have since closed, and now the program offers clinics at seven sites.

Sustaining This Innovation

  • Build name recognition: For the first few years, many patients and professionals thought the program was connected with Healthcare for the Homeless. Staff had to work hard to explain the difference and build name recognition for Women of Means.
  • Use paid nurses to support clinicians and expand services: The program originally had no paid staff. However, the addition of nurse support allowed for more intensive case management and followup services. At present, budget restrictions have prevented Women of Means from hiring additional nurses. However, additional nurses are needed, because demand for services remains high and an adequate supply of volunteer physicians exists.
  • Promote benefits to community stakeholders: Community stakeholders may be willing to support the program once they understand its potential benefits. For example, local hospitals and government agencies can save money when homeless patients receive program services that reduce the demand for expensive ED or inpatient care. Raising awareness of these kinds of benefits can help to build relationships and potentially secure program funding.

More Information

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Contact the Innovator

Roseanna Means, MD
President and Chief Medical Officer, Women of Means, Inc.
Internal Medicine, Brigham & Women's Hospital
Associate Clinical Professor of Medicine, Harvard Medical School

Women of Means Administrative Office
148 Linden St., Suite 208
Wellesley, MA 02482
Phone: (781) 239-0290
Fax: (781) 235-6819
E-mail: RMeans@womenofmeans.org

Innovator Disclosures

Roseanna Means reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section below.

References/Related Articles

Bonin E, Brehove T, Carlson C, et al. Adapting Your Practice: General Recommendations for the Care of Homeless Patients, 50 pages. Nashville: Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2010. Available at: http://www.nhchc.org/wp-content/uploads/2011/09/GenRecsHomeless2010.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Footnotes

1 Quirk M. Homelessness in the City of Boston, Winter 2008-2009 Annual Census Report. Office of the Mayor, City of Boston. December 15, 2008. Available at: http://www.bphc.org/healthdata/other-reports/Documents/2008-2009Key_Findings_ESC.pdf.
2 Bonin E, Brehove T, Carlson C, et al. Adapting Your Practice: General Recommendations for the Care of Homeless Patients, 50 pages. Nashville: Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2010. Available at: http://www.nhchc.org/wp-content/uploads/2011/09/GenRecsHomeless2010.pdf.
3 National Coalition for the Homeless. Domestic Violence and Homelessness, NCH Fact Sheet #7. August 2007. Available at: http://www.nationalhomeless.org/publications/facts/domestic.pdf.
4 Lewis JH, Andersen RM, Gelberg L, et al. Health care for homeless women: unmet needs and barriers to care. J Gen Intern Med. 2003;18:921-8. [PubMed] Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494940/pdf/jgi_20909.pdf.
5 Interview with Roseanna Means, MD, January 21, 2011
6 Donohoe M. Homelessness in the United States: History, Epidemiology, Health Issues, Women and Public Policy. Medscape Ob/Gyn & Women’s Health. 2004;9(2). Available at: http://www.medscape.com/viewarticle/481800.
7 Women of Means Proposal to the Blue Cross Blue Shield of Massachusetts Foundation, October 12, 2010
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Original publication: May 11, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 23, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.