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Social Work in Health Care

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Co-Location of Health Care Services for Homeless Veterans: A Case Study of Innovation in Program Implementation

Jessica Blue-Howells LCSW , Jim McGuire PhD LCSW & John Nakashima PhD MSW

To cite this article: Jessica Blue-Howells LCSW , Jim McGuire PhD LCSW & John Nakashima PhD MSW (2008) Co-Location of Health Care Services for Homeless Veterans: A Case Study of Innovation in Program Implementation, Social Work in Health Care, 47:3, 219-231, DOI: 10.1080/00981380801985341

To link to this article: https://doi.org/10.1080/00981380801985341

Published online: 11 Oct 2008.

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Social Work in Health Care, Vol. 47(3) 2008 Available online at http://swhc.haworthpress.com

© 2008 by The Haworth Press. All rights reserved. doi:10.1080/00981380801985341 219

WSHC0098-13891541-034XSocial Work in Health Care, Vol. 47, No. 3, June 2008: pp. 1–20Social Work in Health Care

Co-Location of Health Care Services for Homeless Veterans: A Case Study of

Innovation in Program Implementation Blue-Howells, McGuire, and NakashimaSOCIAL WORK IN HEALTH CARE

Jessica Blue-Howells, LCSW Jim McGuire, PhD, LCSW

John Nakashima, PhD, MSW

ABSTRACT. This case study examines how the Veterans Affairs Greater Los Angeles Healthcare System (GLA) improved homeless vet- eran service utilization through program innovation that addressed service fragmentation. The new program offered same-day co-located mental health, medical, and homeless services with a coordinated intake system.

Jessica Blue-Howells is Study Coordinator, the VA Greater Los Angeles Healthcare System, West Los Angeles Healthcare Center, Los Angeles, California.

Jim McGuire is VA Program Manager, Homelessness Prevention and Incarcer- ated Veterans Programs, and VA NEPEC Project Director, CHALENG Evalua- tion, at Department of Veterans Affairs Northeast Program Evaluation Center (NEPEC) and UCLA School of Public Policy and Social Research, West Los Angeles Healthcare Center, Los Angeles, California.

John Nakashima is Program Analyst, Veterans Affairs Greater Los Angeles Healthcare System, West Los Angeles Healthcare Center, Los Angeles, California.

The authors acknowledge the program innovators at Veterans Affairs Greater Los Angeles Healthcare System: Steve Berman, MSW, Robert Ely, PhD, William Daniels, MSW, Debbie Dyckoff, RN, MSN, Mariquita McBride, MSW, Joan Brosnan, RN, PhD, and Gloria Martinez, RN, and the dedicated primary care, homeless, and mental health staff who implemented the innovation and made high quality service to homeless veterans a reality.

Address correspondence to: Jessica Blue-Howells, VA Greater Los Angeles Healthcare System, West Los Angeles Healthcare Center, 11301 Wilshire Blvd., Mail code 10H-5, Building 206, room 112A, Los Angeles, CA 90073 (E-mail: [email protected]).

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The program is analyzed using a framework proposed by Rosenheck (2001) that has four phases: the decision to implement, initial implementa- tion, sustained maintenance, and termination or transformation. GLA was able to successfully implement a new program that remains in the sustained maintenance phase five years after the initial decision to implement. Key factors from the Rosenheck innovation model in the program’s success included coalition building, linking the project to legitimate goals, program monitoring, and developing communities of practicing clinicians. The key lesson from the case study is the need for a coalition to persistently problem solve and act as advocates for the program, even after successful initial implementation. Social work leadership was critical in all phases of program implementation.

KEYWORDS. Program innovation, program implementation, homeless, veterans

INTRODUCTION

People who are homeless have many health needs (Institute of Medicine, 1988; Interagency Council on the Homeless, 1992; O’Connell, 2004; Randolph, Balinsky, Leginski, Parker, & Goldman, 1997; Wood, 1992). Homeless people are at higher risk than non-homeless populations for med- ical problems such as hypertension, diabetes mellitus, upper respiratory infections, gastrointestinal problems, and podiatry problems (Gallagher, Anderson, Koegel, & Gelberg, 1997; Wright & Weber, 1987). Although people who are homeless have great need for health care services, they often underutilize health care (Kushel, Vittinghoff, & Haas, 2001). Barriers to care can be divided into two types: patient-related (e.g., lack of personal health insurance, competing survival needs) and institution-related (e.g., negative provider attitudes toward the homeless, limited services, cost of health care coverage) (Gelberg, Gallagher, Anderson, & Kogel, 1997; Kushel et al., 2001).

One major institutional barrier is service fragmentation, in which ser- vices are provided at different locations, and have separate admission pro- cedures (Dennis, Cocozza, & Steadman, 1998; Drury, 2003; Interagency Council on the Homeless, 1992). An example of service fragmentation was the homeless veteran service provision by the Veterans Affairs (VA) Greater Los Angeles Healthcare System (GLA) in the 1990s. Los Angeles has the largest concentration of homeless veterans in the United States:

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There are an estimated 21,424 homeless veterans in the GLA service area (Nakashima, Burnette, McGuire, & Edwards, 2006). By the late 1990s, GLA had developed many transitional housing and rehabilitation pro- grams for homeless veterans (Nakashima, McGuire, Berman, & Daniels, 2004). Yet in 2000 a review of medical care utilization found that GLA-enrolled homeless veterans had only one-third of the medical visits that non-homeless enrolled veterans did, and 22% of homeless veterans enrolled at GLA had never received a full physical or mental status exam (McGuire, Blue-Howells, & Nakashima, 2003)

An important reason for this underutilization was service fragmenta- tion. Services for homeless veterans were offered by separate departments (homeless, mental health, ambulatory care) in different buildings on the campus that were half a mile apart. The existing referral and scheduling systems resulted in wait times of several months for specialty care and even routine examinations. It was believed that these distance and time barriers promoted service underutilization, especially for homeless patients who suffered from serious medical or cognitive disabilities. Clearly, GLA had service access issues.

CASE STUDY PURPOSE

There are two purposes to this article. The first is to examine how GLA improved homeless veteran service utilization by addressing service frag- mentation through program innovation. Program innovation at GLA was based on a model developed at the West Haven VA that integrated medical and mental health care at one clinic location for mental health patients and established the effectiveness of that model (Druss, Rohrbaugh, Levinson, & Rosenheck, 2001). GLA’s program was innovative in two ways: (1) it modified the West Haven model to address the specific needs of homeless patients by co-locating medical, mental health, and homeless services (such as housing and vocational rehabilitation), and (2) it created an access center for homeless veterans that conducted screening, assessment, and referral to all services on a one-stop basis to promote continuity and rapidity of care. (Note: results from a formal evaluation of patient outcomes will be presented in a separate article.)

The second purpose of this article is to examine the implementation process of the new program. This case study is important because while other health care systems have co-located or integrated services for spe- cific patient populations, there are few descriptions of the challenging

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implementation process in the literature (Kirchner, Cody, Thrush, Sullivan, & Rapp, 2004; Wilde, Albanese, Rennells, & Bullock, 2004). One recent example of integrating services offered by Indyk and Rier (2006) examined a linkage approach for multiple providers to address HIV/AIDS services. Our article examines both facilitating factors and barriers faced using a framework articulated by Rosenheck (2001) who synthesized multiple organizational theories to explain the translation of research to practice within complex, bureaucratic organizations.

Rosenheck identifies four phases in program implementation: (1) the decision to implement, (2) initial implementation, (3) sustained mainte- nance, and (4) termination or transformation. Key strategies for successful implementation during these phases are coalition building, linking the new program to legitimate organizational goals, program monitoring, and creating communities of practicing clinicians.

Implementation begins with the decision to implement, in which coalition building (mobilizing stakeholder support) and linking the new program to legitimate organizational goals (i.e., validating the necessity of the program) are critical. Next, in the initial implementation phase, the model specifies pursuing and securing commitment of resources (funding, staffing, physical plant, etc.) as the strategy that allows the program to begin. Program monitoring (process evaluation) during this phase facili- tates implementation by ensuring the new program adheres to program design and goals.

As the program matures, the model indicates that sustained mainte- nance requires a strategy of maintaining continued institutional support for funding and other resources. Also critical is participation from new communities of practicing clinicians. These communities are providers from different disciplines and clinics who coalesce into a team committed to improving and maintaining the program. Thus, the program innovation becomes institutionalized as its stakeholders accept the new program as a standard of care.

Sustained maintenance is a desirable end goal. Some programs, however, enter a final stage, termination or transformation, in which the program closes or its goals and practices are radically altered so it no longer resem- bles its original form. Reasons for program termination/transformation include: shifts in organizational goals/objectives, de-emphasis of certain pro- gram elements, and lack of successful outcomes to justify its continuation.

The following sections follow the Rosenheck implementation frame- work with its key concepts to explain GLA’s program innovation in serving homeless veterans.

Blue-Howells, McGuire, and Nakashima 223

THE DECISION TO IMPLEMENT

The leader of the implementation effort was GLA’s Community Care Careline director, a social worker, whose responsibilities included the medical center’s homeless programs. At GLA, he had developed a reputa- tion for creating innovative programs that addressed patient need and reduced medical center costs through greater efficiency (Nakashima et al., 2004). In early 2000, the Community Care director and his staff devel- oped a VA grant proposal to create an integrated system of clinics for homeless veterans to be housed in one building. The proposed program would be based on a primary care/mental health model piloted at the West Haven VA.

As a crucial first step, the Community Care director built a coalition of decision makers. Coalition members were identified based on their exper- tise and their authority over important resources (such as mental health and substance abuse services). Importantly, the GLA Medical Center director was informally part of the coalition. The Medical Center director believed the new program would better meet the health needs of homeless veterans, a legitimate organizational goal because homeless veterans were a national VA priority, special needs population. Also, from an efficiency perspective, the new integrated program would free up general primary care resources for GLA to serve non-homeless veterans. The program was also in line with VA’s new Advanced Clinic Access program, which pro- moted increased efficiency by matching patient demand with clinic resources.

The proposed program’s merit and its support from the GLA Medical Center director and other managers made the proposal attractive to VA Central Office (VACO) funders. In January 2001, the proposal was approved for $1.5 million for 2 years of VACO funding to be matched by $2.2 million in local funds to launch the innovation.

Importantly, the new program faced pre-implementation barriers because of finances. The Medical Center was running an annual budget deficit of $10–15 million. Although the program had grant funding, it still needed resources from other GLA departments for implementation. Many of these financially strained departments were reluctant to commit resources. For example, Ambulatory Care managers were afraid they would have to temporarily assign existing primary care staff to the new program (an overall GLA hiring freeze in 2002 delayed the hiring of new staff—even when grant funding was available for the new position). In response, the coalition explained to Ambulatory Care managers how the

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new program would reduce the overall demand on Ambulatory Care by providing primary care services for homeless veterans (about 6,000 patients receive homeless services annually at GLA). After some discus- sion, Ambulatory Care agreed to assign a primary care physician provider for the new program’s startup.

The coalition also had difficulty in getting cooperation from Engineering, which controlled building usage. The proposed program site, a three-story building on the West Los Angeles campus, needed costly renovation including flooring, re-wiring, and installation of a new cooling/heating system. To address budget concerns about the renovation, the coalition met several times with Engineering managers. Ways to efficiently use existing physical resources were identified and agreements reached. Eventually, building renovations were completed.

INITIAL IMPLEMENTATION

In July 2002, the integrated clinic opened. The goal of the new program was to integrate patient care by co-locating programs and services in one building. At this facility a veteran could receive medical, mental health, substance abuse, and housing services—all in one day, thus reducing the chance of appointment no-show. This process was facilitated by a central intake and assessment office (called the Access Center) that evaluated the veteran’s needs and directed the client to appropriate providers in the building. Clinics now co-located in one building (homeless, mental health, primary care) agreed to honor the Access Center’s assessment and provide services on a same-day basis. There was also a future plan to add a medical case manager. This case manager would follow patients with chronic con- ditions to facilitate their ongoing VA care after their initial visit.

One innovation in the program’s early operation was a new model of primary care delivery. Traditionally, GLA assigned each patient a primary care provider to coordinate both general internal medicine and specialty referral needs (Veterans Health Administration, 1998); unfortunately, waiting times for the initial primary care provider visit could take several weeks. In the new program, homeless veterans now had a primary care provider they could see on a same-day basis. Further, the new primary care model focused on services and disease-specific clinical practices applica- ble to a homeless population, including infectious disease screening and treatment, chronic pain management, and hypertension management (Healthcare for the Homeless Information Resource Center, 2004).

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Another success was the effective use of program monitoring in guiding the initial implementation. Social work research staff developed a three- year longitudinal comprehensive program evaluation and a periodic moni- toring process that reviewed the chart of each patient to ensure that services were offered in an appropriate and timely manner. The monitoring information was reported to a weekly operations meeting of clinic manag- ers who used the trended data to identify problem areas, make corrective adjustments in staffing and programming, and assess the impact of the adjustments. For example, based on aggregate information regarding patient traffic flow and need, clinic managers arranged the schedules of the Primary Care Clinic providers to accommodate more walk-in patients, and instituted an on-call system to offer same-day psychiatry assessments.

The new program also found creative ways to work with other GLA clinics. For example, some homeless patients needed specialty services at the GLA Optometry and Dental Clinics. These clinics, however, were still on a traditional consult/appointment-based system that could require a several-week to several-month wait. To increase access, the program established a same-day system with the specialty clinics. When a home- less veteran needed services, the specialty clinic was called directly; if there was a slot available due to an appointment cancellation or no-show, the homeless veteran was seen immediately.

Despite its early successes the new program faced many challenges. As in the pre-implementation phase, GLA’s ongoing budget crisis was the major issue. A proposed plan to add a Dental Clinic was cancelled because there were insufficient supplemental Medical Center funds. Blanket, cost-saving freezes stalled all hiring— even for the new program, which had set-aside, grant funding for staffing. For example, the Primary Care Clinic could not immediately implement same-day physical exams and walk-in appointments because it did not have a doctor to consult with nurse practitioner staff, and could not institute a nursing triage function due to a nursing shortage. The clinic was also unable to hire the medical case manager as planned in the program model. In response, the program’s coalition persistently presented their staffing requests to the Medical Center executive staff who used their influence with GLA’s Human Resources Department to expedite the hiring process. Eventually, the program did meet many, but not all, of its staffing requirements. (The case manager position remained unfilled and thus the patient medical case management component was not implemented.)

Another significant challenge was the clash of cultures between clinic staffs. For example, the Access Center was staffed with Homeless Clinic paraprofessional technicians who implemented the initial assessment

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plan. Homeless Clinic managers felt that paraprofessional staff—many who were former homeless veterans—engaged patients well and dis- cerned manipulative patient behavior that affected the usefulness of the initial assessment plan. Mental Health and Primary Care Clinic managers, however, believed that the plans should be overseen by licensed staff due to the complex nature of adding medical and psychiatric assessments to the case plan. The issue was resolved by having a clinical social work coordinator oversee all cases and assign the most complex cases to pro- fessional-level staff. Paraprofessional staff were still involved in most cases, resulting in an optimal blend of staff expertise and experience.

Finally, safety was an important consideration. Staff accustomed to working with homeless patients were fearful of mental health patients and staff accustomed to mental health patients were fearful of homeless patients. In response, clinic managers implemented a series of actions including: Professional Assault Response Training (PART) for staff, installation of a building panic alarm system, and establishing a rapid response arrangement with VA campus police. Also, through negotiation with the VA campus police chief and the Medical Center Director, a full- time contract security guard was assigned to the program.

In sum, the program in its initial implementation phase was successful in modifying and adapting its programs and procedures to address the needs of its patients. Challenges such as staffing, clinic culture clashes, and safety concerns were addressed by coalition members meeting, changing practice as necessary, and presenting issues to medical center leadership on an ongoing basis.

SUSTAINED MAINTENANCE OF THE PROGRAM

The sustained maintenance phase of a program’s implementation is characterized by ongoing commitment to its existence by stakeholders including staff and the institution. Stakeholder commitment to GLA’s program innovation came in the form of new communities of practice, GLA management’s approval of the program’s performance, and resource commitment by VA.

Communities of Practice

A key component of sustaining the program was developing communi- ties of practice where clinicians from different disciplines and clinics

Blue-Howells, McGuire, and Nakashima 227

coalesced into a team committed to maintaining and improving the pro- gram. Social workers played a key role in facilitating communication and collaboration between workers, which resulted in communities of practic- ing clinicians. For example, Primary Care Clinic staff worked closely with staff from an on-campus private nonprofit homeless veteran residen- tial program so many of its residents could use the Access Center for their ongoing mental health and medical needs without tying up resources for new, walk-in clients. Another example was Homeless and Mental Health Clinic staffs working together to develop an effective process for same-day psychiatric screening for homeless patients.

GLA Management Approval

The program innovation’s performance convinced GLA management of its value. The program’s patient volume was large. During the four years between opening in July 2002 and March 2006, the new program saw over 9,000 veterans in over 45,000 visits. Although the population was more complex than the general primary care population, the pro- gram’s primary care clinic provider panels were maintained at the same level as the general primary care clinic, with 900 patients assigned to a full-time nurse practitioner and 1,200 assigned to a full-time doctor. In terms of quality, during this same period, the program’s primary care providers were completing recommended health screening and proce- dures at a higher rate than providers at Ambulatory Care services, which provided primary care for the general GLA population. Regard- ing patient safety, there were no incidents of staff members being assaulted or injured by patients during the two years of project pilot funding.

Also, the new integrated homeless program helped attract new patients to GLA. This was important because of VA’s current capitated financing system, which pays each VA medical center a minimum of approximately $3,000 for every patient enrolled and assessed.

Resource Commitment to the Program

Impressed by the program’s success, the VA Central Office added an additional year of funding at the end of the two-year pilot grant. In a short time, the program became institutionalized by VA; that is, it was now considered by the Veterans Health Administration (VHA) to be a standard of care for homeless veterans. The VHA Mental Health Strategic Plan (2005) recommended replication of the homeless veterans integrated care

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model at VA sites nationwide and GLA received numerous inquiries from other VAs on how to implement a similar program.

TERMINATION OR TRANSFORMATION?

As noted in the Rosenheck framework some programs remain in a sus- tained maintenance phase; others terminate or transform into something different from the original model. Now in its fifth year (in 2007), the GLA program innovation is still in a sustained maintenance phase. The basic model of providing co-located services with a central access and intake system was executed faithfully and will likely remain in operation, given ongoing institutional support and the legitimization of the model in the VHA Mental Health Strategic Plan.

PROGRAM AND CASE STUDY SUMMARY

This case study describes an innovative program designed to address lack of timely access to services for homeless veterans by co-locating clinics in one building and creating an access center to coordinate entry to all needed services. Rosenheck’s stage model helped identify significant elements at each stage of its development. The program was successfully implemented and is currently being sustained at GLA.

In terms of program innovation, the GLA integrated homeless project addressed service fragmentation for homeless veterans due to institutional barriers like geographic distance and waiting time. It offered co-located mental health, medical, and homeless services, which were coordinated through one intake system and offered on a same-day basis. The program’s staff developed new innovations like blending traditional primary care and homeless care, which resulted in coordinated and quicker services for veterans. Since its inception, the program has served thousands of home- less veterans, and improved their access to medical care, mental health treatment, and social services. The program has been recognized as a best practice and its profiling in the Veterans Health Administration current mental health strategic plan may result in its replication throughout the national system.

Creation of a coalition and linking the project to legitimate VA-wide goals (i.e., serving homeless veterans) was crucial in getting the program approved by GLA and funded by the VA Central Office. Initially,

Blue-Howells, McGuire, and Nakashima 229

program implementation was fostered by creative problem solving and ongoing program monitoring that helped modify the program to meet the needs of patients. The program’s sustained maintenance can be attributed to stakeholder commitment in terms of providers coalescing into a team of advocates for the program (communities of practice), the Veterans Health Administration (VHA) acknowledging and institutionalizing the program as a best practices model, and VHA and GLA dedicating resources to maintain the program.

Nevertheless, implementation goals were not fully realized or were severely delayed—due mainly to a climate of fiscal restraint at a deficit- burdened medical center. A case management system for assisting veter- ans with chronic illnesses to interface more effectively with specialty clinics was unable to be implemented. Most needed medical center resources and cooperation were obtained, but this required several rounds of lengthy discussion and negotiation with GLA managers. Coali- tion leaders repeatedly and successfully argued that treating homeless veterans and getting them off the streets was an essential institutional goal for GLA.

The most important lesson from this case study is the need for a dedi- cated coalition of leaders to persistently problem solve throughout the implementation process. The GLA coalition was critical in gathering resources needed in addition to grant funding such as staffing, and building renovations and repairs. Building a coalition is an important first step to a successful implementation. Coalition members should be selected for their expertise, their authority (power) in the organization, and their diligence.

In this project, social workers took the lead in identifying the need for the clinic— that a vulnerable population lacked access to critically needed health care. Social workers recognized that a project of this scope could not succeed without intensive collaboration over time with other disci- plines, such as nursing, medicine, and psychiatry. Social work engaged these disciplines in the multiple tasks leading to the implementation and operation of the new program, managing interdisciplinary conflict as it arose. Social work leadership was critical in sustaining program mainte- nance, providing process evaluation as the program was implemented, and organizing and encouraging development of communities of practic- ing clinicians. Social work researchers developed and executed the pro- gram evaluation. These core social work values and skills aided organizational change and guided and sustained this innovative program that ensured that this underserved veteran patient population actually obtained the services they needed.

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DATE RECEIVED: February 23, 2007 ACCEPTED FOR PUBLICATION: April 9, 2007