SummaryThe Women of Means program makes barrier-free, personalized health care and case management services available to homeless women in the Boston area as a Medical Home Without Walls, with specialized, more intensive primary care and care coordination services for vulnerable poor and homeless women over the age of 65 under an accountable care organization contract for its unique Elder Care program. Volunteer clinicians visit shelters regularly to provide core services of free walk-in episodic acute and preventive care, counseling, referrals, and routine diagnostic testing. Paid nurses and a community health worker 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 physician 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 65 with diabetes and hypertension, and saved an estimated $15 million per year by reducing the need for expensive inpatient and emergency department care.
See Description, Problem Addressed, Results, and Resources for new information about the expansion of the program (updated May 2014).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 65), along with pre- and post-implementation comparisons of select outcomes for women over 65 and staff estimates of program-generated cost savings.
Developing OrganizationsWomen of Means, Inc.
Date First Implemented1999
Gender > Female; Vulnerable Populations > Homeless; Women
Problem AddressedHomeless 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 3,000 women are homeless, accounting for nearly one-third of the homeless population. Nearly 10 percent of Boston's homeless or marginally housed women are over age 70. Many of these women also have their children with them.1
- Health problems unique to women: Women's gender affects the biology of their diseases and illnesses differently than men's. The safety and trauma issues faced by homeless women are different than those for homeless men, and this impacts how they develop trust and seek help. 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: Clinicians and practice staff unfamiliar with the life challenges of homelessness often expect more from the clients than is reasonable or realistic, resulting in an insensitive and unwelcoming reception and even more obstacles to navigate when women do seek care. Consequently, when these women do visit community health centers, they choose to 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 woman has eight to nine concurrent medical illnesses, and the typical homeless woman 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
Description of the Innovative ActivityThe Women of Means Medical Home Without Walls program makes barrier-free, personalized episodic, planned, and preventative walk-in health care and case management services available to homeless women in the Boston area, with specialized, more intensive Elder Care services for the women who are over age 65 and are homeless or marginally housed. Volunteer clinicians visit shelters regularly to provide free walk-in episodic acute and preventive care, counseling, referrals, and routine diagnostic testing. All services are delivered in a trauma-informed manner. 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 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 women using shelter services can receive care by signing up on a clipboard set out at the shelter. They do not have to use their real names 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 are trauma-informed and 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, over-the-counter medicines, 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, blood glucose, and urinalysis. Offering these tests onsite serves to eliminate a potential barrier to diagnosis and followup care.
- Acute interventions: Clients can receive asthma nebulizer treatment, wound care, and prescriptions to treat short-term illness with followup arranged at the shelter or with the client’s PCP, thus preventing overuse of emergency departments.
- Elder Care Program: Enrolled clients are covered by a primary care team comprised of a geriatric nurse practitioner and primary care physician through a partnership with Boston Medical Center, with Women of Means clinicians providing adjunctive “gap” care and care coordination. Elder Care clients receive a cell phone, free transportation, fast-track housing assistance, home care services, care coordination, elimination of co-pays, support by a Community Health Worker, and coverage for necessary items such as dentures, hearing aids and eyeglasses.
- 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 2013, the Medical Home Without Walls Elder Care Program provides primary care, care coordination, supplementary coverage, intensive case management and followup services to homeless and marginally housed women over age 65. Through collaborations with other agencies, the program seeks to address the needs of these most vulnerable women, who have even higher rates of chronic illness, neurological and psychiatric illness, history of abuse, and lack of executive function. Data from the first year demonstrate cost savings to the Commonwealth through prevented ER and inpatient stays for this cohort.
- 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 published a curriculum that introduces topics pertaining to medical care for homeless women for the novice provider.
- 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 InnovationRoseanna 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.
ResultsThe program has enhanced access to medical and social services for thousands of homeless women, improved health outcomes for women over 65 with diabetes and hypertension, and saved an estimated $15 million per year by improved management of chronic diseases, more consistent follow up, and by reducing the need for expensive inpatient and emergency department (ED) care.
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 65), along with pre- and post-implementation comparisons of select outcomes for women over 65 and staff estimates of program-generated cost savings.
- Enhanced access for vast majority of area's homeless women: Since its start in 1999, Women of Means has completed over 90,000 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 65 percent of the city's homeless women (2,000 out of the estimated 3,000 homeless women in the area).1,5
- Enhanced access, better outcomes for aging homeless women: In May 2013, Women of Means launched a unique accountable care organization senior care option-supported pilot designed to improve health and health care access for up to 50 homeless and marginally housed women over age 65 who are dependent on shelters for their daily needs. Preliminary data from the first six months suggest the program has enhanced access and improved health outcomes, as outlined below:
- Enhanced access: Women over 65 who enroll in the Medical Home Without Walls Elder Care Program have access to a geriatric Nurse Practitioner, Primary Care Physician, Community Health Worker and social services provided through a partnership between Women of Means and Commonwealth Community Care at Boston Medical Center. Clients are seen in locations that are the most convenient for them—at the shelter, in their homes, in public venues, on the streets. Support services such as cell phones, rides, and elimination of co-pays are examples of ways that improve compliance and access.
- Better outcomes: Women enrolled in the Elder Care program demonstrate increased understanding of their health problems, increased compliance with treatment plans, and improved health literacy.
- Significant (estimated) cost savings: Annualized data from the first six months of the Elder Care program show that this model is on track to prevent 45 Emergency Department visits and 14 Inpatient Hospitalizations a year. In Massachusetts, the average ED visit costs $1,000-$2,000. The average uncomplicated inpatient hospitalization costs $10,000-$15,0007
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 2013, the program employed nine part-time nurse care managers, Dr. Means (ED/Chief Medical Officer), a director of operations, a part-time community health worker, an office manager, a part-time grant writer, and a part-time medical director.
- Costs: In 2013, the program budget expenses totaled $615,185, which covered employee salaries, office space, and other administrative expenses. In 2014, the budget increased to $730,520 with the addition of new staff, including a part-time nurse care leader and the increase of the community health leader role to full-time status.
Funding SourcesYawkey Foundation; Covidien; Liberty Mutual Foundation; SWAN Society; George and Alice Rich Charitable Foundation; Horncrest Foundation; Eastern Bank; Little Family Foundation; Old South Church; Rockland Trust; Ward Foundation; Belmont Savings Bank; BNY Mellon Charitable Giving Program; Boston Jewish Women's Fund; Pearson Foundation; Campbell and Hall Charity Found; CVS Community Grant; Danversbank Charitable Foundation; Harvard Pilgrim Health Care; Agnes M. Lindsay Trust; MA Women's Home Missionary Union; Middlesex Savings Bank; Natick Rotary; Needham Savings Bank; Ronald McDonald House Charities of Eastern New England; The Ward Foundation; Wellesley Bank Charitable Foundation; Sailors' Snug Harbor of Boston
Tools and Other ResourcesStaff 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 (firstname.lastname@example.org).
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. The addition of a community health worker in 2013 allowed the Elder Care program to flourish, and enhanced the organization’s reach and impact into the homeless community. At present, budget restrictions have prevented Women of Means from hiring additional nurses. However, additional nurses and community health workers 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.
Contact the InnovatorRoseanna 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
Innovator DisclosuresRoseanna 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 ArticlesBonin 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 Reader® software .).
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 Harvard University CAP (Community Actions Partners) Team Report on Women of Means’ Medical Home Without Walls Pilot, April, 2014. Hospital cost basis data from Brigham & Women’s Hospital, Boston, MA.
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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: July 16, 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.