NHCW 2017: Breaking down the walls between housing & health

Aug 15, 2017

While he waited for his name to rise to the top of the Central City Concern housing wait list, Glenn O. lived out of his van in northwest Portland. As he walked back to where he had last parked, he found his van stolen. Gone. And with it, all his possessions, including his dentures.

Not long after, he moved into CCC housing. But even with a roof over his head, his troubles weren’t over. The doctor he had begun seeing wanted him to eat healthier, but without dentures, the list of foods he could eat was short. What he could eat, and how he ate them, led to intestinal problems and months of feeling sick and uncomfortable.

He called his insurance to see if they would cover new dentures. After all, they were stolen, not carelessly lost. They said that they could only cover new dentures once every 10 years. He’d only had his dentures for three.

Glenn went back to gumming his food, feeling unhealthy, and going against his doctor’s orders.

• • •

Moving into Central City Concern permanent housing is often reason enough for our new residents to feel good about their trajectory. The assurance of having a roof over one’s head feels like a giant step forward toward something better. Indeed, we know that having housing is one of the most significant determinants of health, so becoming a resident of CCC housing is definitely an occasion to cheer.

However, being housed isn’t a guarantee that better health is on the horizon. Even for residents of CCC housing, especially those with more complex health care needs, successfully engaging with CCC’s health care services—or any health care services, for that matter—can feel like a world away. The connection between housing and health care is crucial: how well a resident's health needs are met is tied closely to a resident’s likelihood of successfully staying in housing, says Dana Schultz, Central City Concern’s Permanent Supportive Housing Manager.

Though CCC provides both housing and health care, the nature of the programs, as well as privacy considerations, have traditionally made it difficult to share information between the two areas of service. But where Dana saw walls, she also saw an opportunity. The situation called for a way to put teeth behind a core belief that housing is health. That way? A program called Housed and Healthy (H+H).

"Our supportive housing program realized that we can’t distance ourselves from our residents’ health—it’s everything to them and it’s everything to us."

“We started Housed and Healthy as an initiative to better support our residents’ health by engaging with them where they are: in our housing,” Dana says. “Our supportive housing program realized that we can’t distance ourselves from our residents’ health—it’s everything to them and it’s everything to us.”

The Housed and Healthy program serves to improve the connection between health clinics—be it CCC’s own Old Town Clinic and Old Town Recovery Center or other community providers—and CCC’s supportive housing program, and vice versa. Since H+H started, all new residents of CCC’s permanent housing are given a health assessment so that staff can gain a fuller picture of the new tenant. They are asked about their health insurance status, any chronic health conditions they may be dealing with, and who, if anyone, their primary care provider is.

Perhaps most importantly, new residents are asked to sign a release of information, which unlocks the line of communication between CCC’s housing and health service programs.

“Once the two program areas can start talking, we can immediately map out a web of support,” says Dana. “Our clinic can flag the resident’s electronic health record to show that they live in our housing and note who their resident service coordinator is in case they need their help reaching out to a patient. In turn, our resident service coordinators can know which providers and clinics their tenants are connected to in case health issues arise.”

Housed and Healthy represents a big shift in the way supportive housing sees its role in the well-being of its residents. Housing staff are integral to extending health care out from the clinic setting into where their patients live.

The health assessment can also help H+H coordinators identify potential issues—related to their physical or mental health, or to substance use disorder—that, if unaddressed, could result in a resident losing their housing because of violations that put the safety and peace of the rest of the housing community at risk.

“In the past, we’ve seen people not succeed in our housing for reasons that, in retrospect, were preventable,” she says. “If we know what to look out for and the team of support people we can coordinate with, we can put out fires before they really burn down a person’s entire life.”

Housed and Healthy represents a big shift in the way supportive housing sees its role in the well-being of its residents. Housing staff are integral to extending health care out from the clinic setting into where their patients live. H+H even brings opportunities for health education, such as chronic pain workshops and classes like Cooking Matters, straight to residents. In doing so, the chances that patients continue to have a place to live increase.

Glenn, who had seen Dana in his building frequently as part of her work as the H+H Coordinator, approached her about his denture problem. His issues didn’t put him at high risk of losing his housing yet, but he wanted to follow his doctor’s eating advice. He was, after all, nearly three years sober, and he wanted to continue feeling healthier.

She promised him that she’d look into it. She consulted with Glenn’s Old Town Clinic care team. She researched resources and made countless phone calls. Several weeks later, she gave Glenn the best news he’d received since learning that he had his own CCC apartment: she found a city program that would cover nearly the entire cost of new dentures.

“Dana did all the work I didn’t know how to do. The questions she asked me sounded like she knew a lot about what I needed,” Glenn says. “Now that I have dentures again, oh yeah, I feel healthier now. I’m so grateful to her.”

While Housed and Healthy is ostensibly a housing program, it functions as a way to not only expose residents to the many ways to better health, but as a de facto arm of health services that can reach into where their patients live. Gaps in care get caught and filled; residents are supported in better utilizing health care services; and people like Glenn find trustworthy faces to bring health-related concerns.

“Our housing staff want to see our residents healthier; health care providers want to see their patients housed,” Dana says. “It just makes sense.”



Medicaid Waiver Extension is Good News for Central City Concern

Jan 13, 2017

On Friday, Jan. 13, Governor Brown announced the federal government extended Oregon’s Medicaid Demonstration Waiver for another five years, effective immediately to run through June 2022.

“This is great news for Central City Concern,” said Executive Director Ed Blackburn. “As a health care provider serving people with very low incomes or experiencing homelessness, we have many patients who are highly dependent on Medicaid to access medical, mental health, and substance use disorder treatment.”

In 2013, the year before Medicaid expansion in Oregon, 47 percent of CCC’s patients were uninsured; two years later in 2015, only 11 percent of CCC’s patients lacked health insurance coverage. This expansion of Medicaid coverage improved CCC patients' access to needed care as well as enabling CCC to offer a more intensive care model that responds appropriately to the needs of these high-risk populations. Without Medicaid expansion, CCC could lose the capacity to serve as many as 2,000 homeless and very low-income patients.

“We treat every patient as an individual,” said Blackburn, “and many of those individuals rely on the Oregon Health Plan to access desperately needed services. Lisa G. is just one example of the many people who need this support and benefited from Oregon’s Medicaid expansion here at CCC.”

Lisa G. was terrified of losing her health insurance. Before Medicaid expansion, the Oregon Health Plan denied her coverage three times. “It’s something I think about all the time. Without the Oregon Health Plan,” Lisa said, “I just don’t know where I’d be.”

Lisa, 23, used drugs such as heroin and methamphetamine for five years. She also struggled with bipolar disorder, which further complicated her ability to stop using drugs. She tried quitting with no luck, until eight months ago when she accessed recovery support services through CCC. In Lisa’s case, medication assisted treatment helped her tackle her opioid addiction, so she could then focus on her severe bipolar disorder and other medical issues at CCC’s Old Town Clinic.

Lisa now lives in supportive alcohol and drug-free recovery housing and works in CCC’s On-Call Staffing program. She hopes one day to become a peer mentor and help others to overcome their opioid addiction. Without Medicaid expansion, Lisa wouldn’t have had access to critical recovery services that led to integrated health care, housing and employment services.

“Medicaid not only supports these individuals in their health and well-being,” said Blackburn, “but also leverages other resources such as housing and employment, further enhancing the health and well-being of our entire community. Though there are uncertainties about health care on the national scene, we’re tremendously relieved Oregon’s Medicaid Waiver will continue for five more years.”

CCC is a large non-profit organization, founded in 1979 in Portland, OR, that serves people experiencing or vulnerable to homelessness by providing health care and recovery services, housing, and employment services. In the last year, CCC helped more than 13,000 people, most through our 11 Federally Qualified Health Center (FQHC) sites that offer integrated behavioral health and primary care. For more information, visit centralcityconcern.org.



CCC Outreach Workers Fill Gaps in Health Care

Oct 21, 2016

On Monday, PBS Newhour aired a fascinating and insightful segment on the rise of utilizing community health workers—already popular in other parts of the world like Sub-Saharan Africa—to better serve vulnerable and hard-to-reach patients. (You can watch the video above or on the PBS website.) As the segment makes clear, community health workers play a vital role in helping patients improve their health.

At Central City Concern, a number of our specialized health care programs rely on Outreach Workers to engage those we serve in direct, meaningful ways that truly exemplify our commitment to meeting patients where they are.

The Community Health Outreach Workers (CHOW) team works to bring individuals who are newly enrolled in the Oregon Health Plan (Oregon’s state Medicaid program) into our Primary Care Home, where patients can find barrier-free access, team-based care, integrated mental health and addiction treatment, and additional wellness resources. They’ve also been working with the care teams at Old Town Recovery Center, CCC’s mental health clinic, to help their clients get connected with primary care.

CHOW team members may meet people on the street, at shelters or hospitals, or in their own homes, and often check in with patients to ensure that they are engaged comfortably into the care available to them.

Members of the CCC Health Improvement Projects (CHIPs) team, also known as our Health Resilience Specialists, are embedded in the four main care teams at CCC’s Old Town Clinic (OTC). CHIPs team member work closely with OTC patients (what we call “high touch” support) who have shown a high rate of hospital emergency utilization, helping them decrease unnecessary hospital use by providing intensive case management and addressing social determinants of health. CHIPs team members meet patients at home, on the street, in the hospital, or wherever else the patient needs engagement to happen most.

For those already living in our housing, CCC’s Housed + Healthy team provides a direct pipeline from housing to CCC health care. By performing a needs assessment with new residents as they move into their CCC home, the Housed + Healthy team can identify high needs residents who have gaps in their health care support. The Housed + Healthy team can streamline the referral processes to connect residents to care and even increase coordination between service providers. Further, our Housed + Healthy team provides on-site wellness education programming to encourage healthy living.

The work and impact of Outreach Workers are so important that they can be found beyond the three teams we highlighted here; programs like CCC's Bud Clark Clinic, among others, also lean on Outreach Workers to build relationships with those who are vulnerable in order to connect them with basic health care and services.

The flexibility of CCC’s Outreach Workers allows them to bring care and compassion to our patients. Maintaining and improving health outcomes takes work outside clinic walls, and our Outreach Workers are there to walk that journey with those we serve!



5,000 Covered and Counting!

Apr 28, 2016

This week, Central City Concern hit an exciting health insurance milestone. As of April 21, 2016, Central City Concern Outreach Specialists have helped more than 5,000 people enroll in the Oregon Health Plan or other affordable health coverage, or renew their coverage. Since the Affordable Care Act expanded Medicaid in Oregon and many other states, we have seen the great benefits for the people we’ve helped enroll.

Our outreach efforts started on October 1, 2013 and have continued steadily since then to enroll as many CCC clients, residents, and community members as possible in the Oregon Health Plan (or, if they’re over income for OHP, in other affordable health coverage).

Our full time Outreach and Enrollment Specialists Conor Gilles and Alycia Reynolds (as well as former specialists Kevin Chou, Juliana DePietro, and Eric Reynolds), supervised by Benefits & Entitlements Specialist Team (BEST) Program Manager Kas Causeya, who coordinates CCC’s outreach and enrollment program with Executive Coordinator E.V. Armitage, have done an outstanding job enrolling individuals.

Even with our incredible Specialists, efforts to help people obtain health coverage are a team undertaking that stretches across CCC programs and locations. In addition to the Specialists, CCC has staff members who are trained enrollment "Assisters," as well as many staff who have done some support work in one way or another over the last few years. Current staff members who help with OHP enrollment include Sabra Eilenstine of BEST, Angie Gaia of Risk Management, Gabi Gallegos and Sylvia Woods of Eastside Concern, Abby Lee of Hooper Detox, and Dana Schultz of Supportive Housing.

Most of the enrollments have taken place at Hooper Detox, Old Town Clinic, Eastside Concern, and CCC Housing sites, but we’ve also enrolled many people at all other CCC programs sites. Approximately 20% of enrollments have taken place through outreach at Transition Projects, Inc., Union Gospel Mission, Portland Rescue Mission, and other community partners.