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Bridging the health gap of older individuals who are chronically unhoused
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Bridging the health gap of older individuals who are chronically unhoused
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Bridging The Health Gap of Older Individuals Who Are Chronically Unhoused Tamara Young A Capstone Project Proposal Presented to the Suzanne Dworak-Peck School of Social Work University of Southern California In Partial Fulfillment of the Requirements for the degree Doctor of Social Work DSW Program Ron Manderscheid, PhD August 2023 ii Table of Contents Executive Summary ....................................................................................................................... 1 Problem ....................................................................................................................................... 1 Related Grand Challenges ........................................................................................................ 3 Methodology ............................................................................................................................... 4 Theory of Change ....................................................................................................................... 6 Contribution ............................................................................................................................... 7 Implementation Plan ................................................................................................................. 7 Abtract….………………………………………………………………………………………………………………………………………….9 Positionality Statement…………………………………………………………………………10 Problem of Practice and Literature Review ............................................................................. 12 Conceptual / Theoretical Framework ........................................................................................ 15 Proposed Solution ........................................................................................................................ 19 Project Description .................................................................................................................... 19 Theory of Change (ToC) ............................................................................................................ 19 Solution Landscape .................................................................................................................... 21 Prototype Description ................................................................................................................ 23 Methodology ................................................................................................................................. 31 Implementation Plan .................................................................................................................. 34 Challenges .................................................................................................................................. 36 Ethical Consideration and Applying Design Justice Principles ................................................. 38 Conclusion and Implications ..................................................................................................... 39 References .................................................................................................................................... 44 Appendices ................................................................................................................................... 49 Appendix A: Logic Model ......................................................................................................... 49 Appendix B: Design Criteria ..................................................................................................... 50 Appendix C: Action Plan ........................................................................................................... 51 Appendix D: Budget Template .................................................................................................. 53 Appendix E: Collaboration Contacts /Letters ............................................................................ 54 Appendix F: Pretreatment Guides .............................................................................................. 55 Appendix G: Training Toolkit ................................................................................................... 59 Appendix H: Disclosures ........................................................................................................... 60 iii Appendix I: Confidentiality Form ............................................................................................. 63 Appendix J: Photograph/Video Release Form ........................................................................... 64 Appendix K: Protected Health Information ............................................................................... 66 Appendix L: Emergency Contact Form……………………………………………………….67 iv Acknowledgment Words cannot express my gratitude to my professor, Dr. Ron Manderscheid, for his invaluable patience and feedback. Also, without the help of my defense committee, Dr. Brenda Wiewl and Dr. Rice, I could not have embarked on this journey. I also appreciate the feedback and moral support of my colleagues. I would like to express gratitude to God, the one who saved my life, and my wonderful mother, who left a lasting impact on me and my family. As the youngest of her five children, she prioritized education. I fondly remember accompanying her to her classes at City College in New York City, where she diligently worked and attended courses twice a week. It would be inappropriate for me to refrain from mentioning my family. Ja’Quari Futrell, Tanasia Futrell, and Dominique Young. Dominique has been my unwavering support, encouraging me during tough times and taking care of her siblings while I pursued my BA in liberal arts. Her support remains constant. Tanasia Futrell motivated me to return to school and earn my GED and all my degrees (BA, MSW, and DSW). When she was seven, she asked, “Why don’t you attend school or work?” I had no explanation at all. I could not help but mourn. I decided to return to school. He taught me how to persevere despite having a cognitive impairment and pushed me to do the same. I deeply appreciate the unwavering support of my professors throughout my academic journey. Dr. Howard Fogel and Iona Duncan have supported me since I began my Bachelor of Arts program at the College of New Rochelle in 2016. Dr. Ref Rodriguez, Dr. Nicole Brown, Dr. Michelle Brock, my colleagues, and Dr. Sarah Schwartz, who encouraged me during my second attempt in my master’s program and DSW program, deserve special recognition. Dr. Danyelle Williams, Dr. Crystal Witherspoon, my Apostle Everton Harris, and Tonette Wardlow, who encouraged and prayed for me continuously. 1 1 Executive Summary Problem The goal of the American Academy for Social Work and Welfare’s Grand Challenge, Eliminate Homelessness, is to utilize innovative thinking, resources, and evidence to end homelessness and improve people’s lives (Henwood et al., 2015). The age group experiencing the fastest growth among unhoused people is those aged 65 and older; by 2030, their numbers will triple (Culhane et al., 2019). In response to this shifting population, researchers have worked to fully describe urgent health requirements, such as the need for palliative care and cognitive decline (Sandham et al., 2022). In Raleigh, North Carolina, the proportion of unhoused single adult men is 56%, while the corresponding figure for single adult women is 18%. According to research studies conducted by Sutherland et al. (2022), unhoused individuals face a higher prevalence of various medical conditions when compared to those who have stable housing. These conditions include asthma (affecting 24% of the unhoused population), diabetes (26% of the unhoused population), lung disease (23% of the unhoused population), severe heart conditions (38% of the unhoused population), kidney disease (27% of the unhoused population), and tobacco use (reported by 63% of the unhoused individuals). There are many barriers to receiving healthcare for the unhoused and chronically unhoused. Recent surveys conducted by this author document the demand for access to medical services that cannot be fulfilled due to transportation barriers. The current healthcare system finds it challenging to provide the adult unhoused population with respectful care and medication. Additionally, this population struggles with access to secure housing due to past and current traumas such as PTSD, depression, mental health issues, substance abuse, and poverty. Researchers found a correlation between racism, oppression, marginalization, a history of 2 2 trauma, and chronic homelessness (Wiewel & Hernandez, 2021). These factors compound the challenges the unhoused and chronically unhoused individuals face, making it imperative for society to address these systemic issues to improve their well-being. The lack of access to healthcare due to unreliable and unaffordable transportation can increase the risk of late-stage diagnosis and even lead to lower life expectancies. Unhoused adults often lack access to services necessary for stabilizing their mental and physical health, which can exacerbate other health conditions (Klop et al., 2018). They also lack access to services to address their sanitary needs, such as laundry, showers, and restrooms. Thus, many conditions related to being unhoused affect long-term health outcomes. Furthermore, there are other factors contributing to this situation. Many unhoused individuals resort to hospital emergency services when their conditions become more severe and life-threatening and they are more likely to have shorter life expectancies (People, 2022). Other obstacles include low literacy levels, limited accessibility, prioritization of necessities over other needs, challenges in developing self-efficacy, ignorance of eligibility requirements, and gaps in knowledge. However, these barriers can be overcome with appropriate types of services. Access to healthcare addresses immediate health needs and plays a crucial role in facilitating connections to housing, employment, and skill-building opportunities. By ensuring access to healthcare, unhoused individuals can receive comprehensive support that addresses their diverse needs and helps them on their path toward stability and improved health outcomes. Raleigh, North Carolina’s unhoused population nearly doubled from the previous year in 2020, with a 99% increase from 2020 and a 68% increase from 2021 (Browne, 2022). Primary care, behavioral health, specialty services, pharmacy, and dental care are all unavailable to the unhoused population. Additionally, accessibility problems related to receiving healthcare are 3 3 linked to a lack of trust by the unhoused population caused by stigmatization, a lack of services that meet the specific cultural needs of a group, and a feeling of being scared by powerful people in the healthcare industry (Thorndike et al, 2022). Transportation services enhance the dignity and health status of individuals facing the daily battle to survive on the streets. This is particularly important for those who have become resigned to their circumstances, knowing they lack the financial means or resources to secure housing. While existing literature on homelessness addresses the various pathways to becoming unhoused, it often fails to address the transportation issue (Bassett, 2013). However, critical barriers based on a lack of transportation must be considered and addressed. For example, it can be difficult for many unhoused people to fill out the paperwork needed to access essential services because they lack a permanent address or phone number. Local healthcare organizations report that Raleigh, North Carolina, requires individuals to be Wake County residents and provide proof of residency, which is nearly impossible for unhoused individuals. Consequently, they are not considered residents of that area. Related Grand Challenges Regarding the chronically unhoused, the Grand Challenge, Close the Health Gap, is connected and intertwined with the Grand Challenge, End Homelessness. Thus, a key issue related to homelessness is that the adult unhoused population in Raleigh, North Carolina, has inadequate access to healthcare and lacks resources for basic needs. This strongly correlates with economic, social, and environmental factors surrounding populations and communities of color. The Grand Challenge, Eradicate Social Isolation, is also related to closing the healthcare gap and ending homelessness because unhoused people experience intense isolation from the rest of society, which often doesn’t understand them at best, and denigrates or insults them at worst. 4 4 To effectively address the Grand Challenge of ending homelessness, solutions should prioritize community partnerships, which help reduce inherent isolation and improve access to services. This involves advocating for effective policies, engaging with federal government agencies, conducting outreach activities, providing access to resources, and offering recovery options (Burns et al., 2020). The intervention developed by this author aims to bridge the healthcare gap for chronically unhoused adults, ensuring increased access to healthcare and other necessary resources while addressing related needs. In Raleigh, North Carolina, it is crucial to bring resources directly to the communities and assist individuals who lack transportation and knowledge in accessing those resources. Achieving this requires effective collaboration with like-minded organizations who have similar values and goals. Methodology The prototype concept was created after much research, helping to define the problem and the target population. Design Thinking, a methodology that places stakeholders at the center of the design process, was utilized to create an effective and innovative intervention. Primary data was collected from stakeholders via surveys and interviews. A survey was used to explore people’s needs and determine if healthcare access was a problem. Then, the impacts were evaluated. The Patient Health Questionnaire, a versatile tool for screening, diagnosing, monitoring, and tracking the degree of behavioral health, was used to assess the well-being and health of the adult unhoused population (Kroenke et al., 2001). This tool also tracked progress once clients started receiving actual services. Secondary research was conducted by reviewing relevant scholarly research. The next step was to design prototype features in preparation for piloting a program throughout the community. Additional data was collected and utilized 5 5 throughout the pilot period to make appropriate changes. Lastly, a final plan was developed and put in place to continue working with individuals who were served throughout the pilot phase. The expectation was that increased availability of programs offering essential services like healthcare, mental health support, employment assistance, housing aid, and resources for everyday necessities such as food and clothing would positively impact the target population’s stability and overall health. Consequently, thorough research was conducted during the design process to identify and include as many relevant programs as possible. These programs were sought after to serve as potential referral sources that could effectively address the specific needs of the target population. Several indicators were identified to be recorded as outcomes to measure the impact of the programs effectively. These indicators include; a) the number of regular doctor visits or programs b) the total number of services received c) the perception of health conditions at first contact and proceeding over time to the present; and d) the number of no-shows to medical appointments. The prototype project will also track how many chronically unhoused adults are served daily or monthly, utilizing a sign-in sheet each time the van transports them. The questionnaire will help identify emerging and ongoing concerns, health behaviors and attitudes, and healthcare conditions that need attention. The prototype project, “Grace Within Transitions,” consists of constructing a bridge for unhoused people through outreach and resource linkage. This approach will aid in connecting them to all available resources and ultimately offer them a second chance at a healthier and more stable life. Older adults who are chronically unhoused and have untreated medical conditions can 6 6 benefit from a service that helps them identify health concerns, provides transportation, and offers ancillary services to meet their needs, ultimately improving their overall health and wellness. The long-term goal is for individuals to secure housing. The prototype includes sanitary needs, healthcare services, outreach, a transportation van, and social support services. The outcome is to continue to provide these services to as many people in the community as possible, thereby increasing stability and housing for the target population of unhoused individuals. To expand its reach, the project will partner with existing well-established organizations. Two organizations, “When People Work” and “Urban Ministries,” have agreed to schedule appointments and provide medical care as part of the outreach and transportation services. Theory of Change To break the cycle of homelessness and heal from trauma, chronically unhoused adults must have access to basic healthcare, which can encourage them to develop skills such as embracing responsibilities, meeting goals, and gaining social and personal self-sufficiency. The project will utilize surveys, observations, and experiments to explore the outcomes that occur once the participants receive services, helping determine the validity of the theory around skill development. It is theorized that when the services remove barriers and the participants gain increased access to medical care and other services, this reinforces and rewards help-seeking behavior and builds communication with service providers who can address their housing, behavioral health, and trauma treatment needs (SAMHSA, 2022). Several professional courses of study can potentially contribute to the analysis of homelessness, encompassing disciplines like sociology, social work, psychiatry, and psychology. According to Bandura’s Social Learning 7 7 theory (McLeod, 1970), change is expected to occur via observation, modeling, imitation, and reinforcement. Contribution The proposed solution aims to support unhoused adults with chronic health conditions in several ways: 1) by halting the progression or spread of diseases, 2) by providing essential services like medications, and 3) by helping them access health insurance. Through this approach, the suffering of those experiencing homelessness will be alleviated, and they will receive the necessary care and support they require. As a result, they can expect to experience more respect from others and, importantly, cultivate self-respect. The underlying intention is to humanize and dignify those who spend their nights in cars or on the streets, recognizing that homelessness can befall anyone, often unexpectedly and unintentionally. Every day, we pass by formerly well-off individuals who were in positions of power but are now unhoused. It is imperative to emphasize the importance of providing increased support to the unhoused as part of our community service efforts. The objective is to shift people’s perceptions of those experiencing homelessness and help build understanding from the general public that even individuals living in extreme poverty deserve respect and kindness. Our nation must pay attention to both those with homes and those without. As time progresses, there will be further debates and significant inquiries concerning the current homelessness situation. Implementation Plan The project’s main target is to help develop a future where unhoused adults are cared for and work towards a self-sufficient future. To achieve this goal, “Grace Within Transitions” has devised an action plan that establishes connections with services addressing short-term and long- term issues. Networking has played a pivotal role in building relationships with various 8 8 organizations and stakeholders involved in the implementation process. Key stakeholders were contacted, and three medical care collaborations were implemented: Divine Restoration Worship Center, Work from Home, and Urban Ministries Organization. Additional community contacts include Stormie D. Forte, a member of the Raleigh City Council serving as vice-chair, focusing on a healthy neighborhood, and Evan Raleigh from the City Manager’s Office, who offered to assist with funding for the non-profit 501C3 organization. The primary goal of the prototype is to reach out to individuals within the community right where they are. Doing so ensures that people with limited resources can access necessary care and potentially pave the way to housing opportunities. During the development of the prototype, a van was donated to transport clients to medical facilities multiple times throughout the week. The van schedule was created, incorporating a complete employee and volunteer staff list to push the project forward. The budget includes reasonable cost projections and revenue from in-kind donations, grant programs, subcontracts with medical service providers and health plans, and advertisements. The budget covers van maintenance, staff wages, supplies, insurance, and other expenses. The project evaluation process will track the impacts on clients who receive services over time. Finally, steps to finalize the budget, considering current and possible future spending, will ensure the full implementation of the project. 9 9 Abtract The challenges of the adult population's health gap can be lessened by constructing a bridge for persons who are homeless through outreach resources, advocacy, and a linkage program within the communities via a transportation van. This proposed project will contribute to addressing the grand challenge of ending homelessness. Even brief periods of homelessness can have serious, long-lasting effects on an individual's well-being and ability to develop personally (chronically homeless, 2021). As a social worker, it is critical to take individual differences and cultural/ethnic diversity into consideration. According to Stafford & Wood (2017), the homeless population has high rates of health disparities, which can affect their longevity and quality of life as well as strain the healthcare system (e.g., primary care and mental health services). To get people off the streets and into health and social support, it is crucial to develop new service innovations and technologies, as well as policies that support healthcare and affordable housing. It will be a significant innovation to use my proposed intervention for adults who are chronically homeless. The van will be used to connect people to healthcare services, which include medical, mental health, prescription, and survival resources for the adult homeless population in Raleigh, North Carolina. These services may include, but are not limited to, a range of health examinations and assessments, triage, employment, housing resources, hygiene supplies such as kits provided, pressure taking, nutritional meals, health education, clothing donation, as well as outreach and case management. Keyword: health disparities, community, chronic homelessness, health services research, and vulnerable population 10 10 Positionality Statement Working on this long-held interest was both exhilarating and nerve-wracking, as I faced unknown obstacles in constructing this prototype. Bridging the health gap for older individuals who are chronically unhoused required me to step out of my comfort zone and fully engage with the issue. This was apprehensive because it meant confronting the challenges faced by chronically homeless adults who have endured without assistance for so long. As someone who has also experienced homelessness, I understand the difficulties associated with regaining a regular life. However, it was enlightening to look forward to meeting my targeted group in the neighborhood and learning about their needs. As previously stated, society often neglects the reality that homelessness should be a concern for everyone, as anyone can be one step away from experiencing homelessness. Moreover, there are misconceptions that every one homeless is there by choice or is labeled as an alcoholic or drug addict, despite not all homeless individuals sharing these experiences. Personal conversations with several individuals in the community have highlighted their worries about societal attitudes, judgments, and misunderstandings. Hearing their stories only fueled my desire to advocate for them, as they deserve a second chance. Society must find ways to bridge the health gap, especially since many of these individuals haven’t visited a doctor in years. Basic needs are a fundamental right for all humans, and pushing for this unfair and senseless goal in our society must be addressed. The prototype, which targets homeless adults, emphasizes outreach and linkage initiatives by directly interacting with them in the community. This project is well-suited for Raleigh, North Carolina, due to the slower pace of governmental systems compared to northern states like New 11 11 York. The daily tasks involve traveling to communities to develop a rapport and collect data through questionnaires about their fundamental information and needs. Additionally, the prototype provides nourishment and hygiene kits, transports them to clinics for medical care, takes them to pharmacies to get medications, and returns them to their drop-off places. The primary objective is to establish rapport, connection, and trust, as lack of access to medical care significantly impacts a person’s ability to seek housing, food, health care services, and employment independently. While working on this prototype, I established a non-profit organization called “Grace Within Transitions” for future implementation. Collaboration with various contacts has been crucial to ensure this project’s success. The prototype has brought forth important issues that need solutions, such as personnel, guidelines, hurdles, incentives, safety standards, and the importance of having a backup plan. The key takeaway is that maintaining consistency with this prototype is crucial, as feedback and advice from others will continue to shape and improve it. 12 12 Problem of Practice and Literature Review The project’s primary purpose is to improve health and wellness for chronically unhoused adults in Raleigh, North Carolina. The adult homeless population experiencing the fastest growth consists of those aged 65 and older, and by 2030, their numbers will triple (Culhane et al., 2019). On any given night, an estimated 553,742 people experience homelessness in the United States, equating to a rate of seventeen people per 10,000 within the general population. Of the total unhoused population, 110,528 individuals, which accounts for 27%, are considered chronically homeless. Among the chronically unhoused, 66% are living on the streets, in cars, in parks, or other nonhuman habitation (National Alliance to End Homelessness, 2021). In the state of North Carolina, there are 9,314 individuals experiencing homelessness on a given day, with an estimated 1,272 chronically homeless adults (USICH, 2019). Homelessness is closely linked to significant health inequalities, such as shorter life expectancy, increased morbidity, being a key driver of poor health, and accumulating adverse social and economic conditions (Stafford & Wood, 2017). The present socioeconomic structure makes it incredibly difficult to offer adequate care to adults who are homeless; nevertheless, this project aims to provide social services, meet people where they are, and focus on their well-being. It is also based on addressing social isolation and discrimination, which are connected to the grand challenge of ending homelessness. Research literature stresses the importance of community partnerships in addressing homelessness and the issues chronically unhoused individuals face (Burns et al., 2020). Solutions include advocating for effective policy, engaging federal government agencies, outreach, equitable access, and recovery (Burns et al., 2020). Many adults experiencing homelessness tend to suffer from medical issues such as hypertension, diabetes, asthma, behavioral problems, and 13 13 skin diseases. Society has stigmatized homeless individuals, creating barriers to medical care, jobs, and housing. Therefore, the long-term goal is to provide suitable and safe housing, medical care, and job opportunities for those experiencing homelessness. Homeless adults face numerous challenges, including limited access to safe housing, mental health support, substance abuse services, and healthcare due to expensive and unreliable transportation. Their complex health needs often worsen due to the avoidance of healthcare services. Lack of access to necessary services further destabilizes their mental and physical well- being (Klop et al., 2018). Addressing the health gap in the adult homeless population requires the implementation of a community outreach and linkage program. Even short periods of homelessness can lead to severe and long-lasting repercussions on a person’s health and hinder their personal growth. Furthermore, there is a possibility that service providers may not be adequately prepared or qualified to assist unhoused individuals. Many providers lack knowledge and empathy, leading to mistreatment or an inability to cater to specific requirements. This highlights the need for better training and awareness among service providers to support the homeless community effectively. Access to reliable and efficient transportation services improves the dignity of those struggling to progress toward achieving housing stability while addressing healthcare needs. Most affordable transportation services require screenings, which often create barriers to access. Research literature tends to focus on the causes of homelessness rather than identifying critical obstacles like reliable transportation access (Bassett, 2013). The nature of homelessness, coupled with the design and implementation of programs, often poses challenges for unhoused adults attempting to access mainstream services. Reliable, affordable, and efficient transportation is a 14 14 significant barrier for individuals experiencing homelessness who seek to enhance their health outcomes, secure employment, and, ultimately, stable housing. There is a direct link between the lack of access to sanitation and increased health issues among unhoused people. Showering and using the restroom in a private and spotless setting enhances the treatment of homeless adults. Debbie Perez, co-founder of Serving Up Dignity with Showers, stated, “We want to bring the discussion back to the idea of dignity, and we feel that it might spark a larger conversation about social justice and the basic human right of access to water and sanitation” (Samuels, 2016). Homeless adults want to feel clean, improve their situation, and have access to basic hygiene and experiences (Leibler et al., 2017). Research shows that individuals who are homeless, compared to those with stable housing, have increased medical conditions. One study found that homeless individuals had higher rates of chronic health conditions than those identified as housed. Researchers found that homeless adults had higher rates of asthma (24% compared to 17%), diabetes (26% vs. 22%), lung disease (23% vs. 11%), severe heart conditions (45% vs. 38%), kidney disease (27% vs. 25%), and tobacco use (63% vs. 38%) (Sutherland et al., 2022). Today homeless adults make up more than half of the homeless population around the world (Culhane, 2019). Healthcare for homeless individuals poses challenges, especially regarding diabetes. While the general population easily manages the condition with insulin and a controlled diet, homeless individuals face obstacles. Refrigeration for insulin storage is unavailable, syringes can be stolen, and they may be wrongly perceived as drug abusers. Additionally, their diet lacks control as soup kitchens provide varied meals without 15 15 specific dietary considerations. Therefore, decision-makers need multisectoral professional skills and qualifications to address these challenges and facilitate communications between social and health services (Plescia et al., 1997). Based on a cross-sectional study of homeless individuals in Boston, it was found that over 60% of them reported washing their hands with soap five or more times per day, despite facing barriers to personal hygiene and self-care (Leibler et al., 2017). Unfortunately, the reduced availability of public toilets in the United States in recent years has had a particularly adverse effect on the hygiene practices of impoverished individuals who rely on these facilities for their daily self-care (Leibler et al., 2017). Homeless individuals experience higher rates of mental illness and substance use compared to housed individuals, resulting in challenges meeting basic daily living and personal hygiene needs. Targeting resources to improve self-care for adult homeless individuals is crucial, as many lack the support of family and friends for assistance. Conceptual / Theoretical Framework Ensuring access to healthcare is a fundamental human right, but the availability of resources is limited. The critical concern lies in the lack of healthcare services for adult homeless individuals, which highlights the scope of the issue. To address this, an effective approach involves establishing healthcare facilities in remote areas where the homeless population can readily access essential services for both their physical and mental well-being. These facilities should also serve as gateways to connect individuals with other relevant resources. Implementing this approach requires the application of diverse strategies. As a result, various obstacles and enablers emerge for adult homeless populations seeking healthcare services. 16 16 Starting with the health care system, the conceptual framework comprises inputs and outcomes. The contributions will look at how health services are accessed and provided and make suggestions for medical and public health professionals to improve the population’s health. The ability to receive various services in a single location is one of the features of health care delivery systems because this is not a common practice in local communities. Society has a negative view of people who are homeless and often assumes the worst about their situation. Being looked after by professionals and caregivers and having the resources to satisfy the fundamental requirements of an adult homeless person can all contribute to maintaining dignity. Many homeless experience abuse, such as being yelled at, being called names, or having undue expectations placed on them regarding rule compliance. However, access to resources should improve the drive to end homelessness, increase healthy connections, and grow a sense of self- worth. The COVID-19 pandemic has significantly impacted homeless individuals’ ability to maintain personal hygiene, as many supporting organizations closed down. Consequently, these individuals have gone for weeks without access to showers or handwashing, crucial steps in reducing their risk of exposure and containing the spread of viruses. Despite the Centers for Disease Control and Prevention’s (CDC) advice on the importance of handwashing to prevent infection spread (Roller, 2020), adult homeless individuals face difficulties in obtaining water or soap for cleanliness. During the pandemic, sharing resources among those experiencing homelessness was discontinued. As a result, some individuals have been compelled to purchase costly buckets of contaminated water as an alternative solution, lacking better options. Homeless individuals can be spotted in various areas of Raleigh, North Carolina, seeking help on the streets. Those currently homeless and lacking substantial assistance receive support 17 17 according to available resources, experience, and feedback. The need for an outreach healthcare service van arises since the adult homeless population requiring specialized behavioral treatments, prescriptions, ongoing primary care, or dental healthcare cannot always access health insurance or transportation. For individuals who cannot or choose not to visit a fixed-site clinic, the services must be provided in a friendly manner. Roller has heard accounts of people who have gone a week or even two weeks without showering when meeting with folks experiencing homelessness in the neighborhood. Businesses were forced to restrict the number of showers provided each day because of the COVID-19 pandemic’s social segregation tactics, which left many who relied on these showers— particularly women dealing with menstruation, pregnancy, and other healthcare issues—feeling helpless, enduring lengthy line waits without giving up, and occasionally resorting to using baby wipes to clean themselves. Healthcare system providers were perceived as lacking knowledge of how socioeconomic determinants of health, persistent trauma, lack of sympathy for patients, their challenges, and prior adversity affected people’s health (Purkey & MacKenzie, 2019). The general mental health, housing, addiction, and difficulties receiving care of older homeless people will be evaluated through surveys, which will be in a multiple-choice format. These surveys will be followed by anticipated interviews, which may last up to 30 to 45 minutes, to summarize the survey feedback. According to Tulane University (2021), mobile healthcare services enhance accessibility and reduce the cost of care, especially in rural areas. The logic model incorporates various services and personnel to reduce the need for long- term medical care among homeless adults. Outputs, such as the Patient Health Questionnaire, will assess the wellbeing and health of older homeless adults. Additionally, staff gatherings will 18 18 be held to train the entire team. A key objective of the program is to deploy outreach workers in the communities to engage with homeless individuals and address their needs. The communities will receive resources and transportation support. Homeless adults will gain access to healthcare, health insurance, hygiene kits, and transportation services. These comprehensive services result in improved healthcare accessibility and insurance coverage for the participants. Moreover, they feel more respected, reducing the spread of viruses and infections (See Appendix A). The study of learned behaviors through observation, modeling, and imitation of new behaviors that are reinforced by other individuals, or models, as developed by psychologist Albert Bandura, is used to examine homelessness (Mcleod, 1970). To break the cycle of homelessness and heal from trauma, adults who are homeless must develop certain skills. By employing the tools of surveys, observation, and experiments to explore the outcomes of homelessness when people receive the healthcare they require, theories can further our understanding of homelessness. Motivational interviewing, a person-centered strategy to elicit and increase motivation to change, is another conceptual approach concerning homelessness. It provides professionals with a helpful foundation for communicating with those who are homeless or are dealing with mental, substance use, or trauma issues (SAMHSA, 2022). The homeless population is frequently stigmatized as being lazy. Societal problems like homelessness are believed to be caused more by the shortcomings of an individual within society than by problems with society. In sociology, the fundamental elements of society, including culture, social structure, socialization, social interaction, organization, and deviance, play a crucial role in understanding homelessness (Smelser, 1994). Analyzing homelessness encompasses various aspects, such as sociology, social policies, psychiatry, psychology, and housing. Socialization emphasizes 19 19 culture, social interaction, organizations, and social structure. By employing sociological methods, we gain insight into homelessness and poverty. This understanding enables us to grasp essential social concepts and identify potential remedies for addressing the challenges faced by individuals within our political and economic community. Proposed Solution Project Description The outreach and linkage program concept involves community engagement to offer outreach, transportation, and connections to various medical services, nutritional meals, pharmaceutical medication, and housing options. According to the article “Sanitation as a Basic Human Right,” the focus is on restoring dignity and initiating broader discussions about social justice and the fundamental human right of access to water and sanitation (Samuels, 2016, para. 14). Homeless individuals are advocating for these basic human rights to be accessible to them. While some have knowledge of available resources, they lack the means to reach appointments and other essential destinations. In Raleigh, North Carolina, certain services can be accessed through bus rides, but passengers might have to walk to their final destinations upon disembarking. Currently, only a few groups provide medical treatment for homeless individuals. Theory of Change (ToC) The Person Dignity Theory emphasizes the well-being of the community. As the theory postulates, the ideal community is based on family, society, nation, humanity, and nature. Removing barriers increases access to help, related to the reinforcement and reward behavior theory, where access is rewarded and reinforced. From experience interviewing a few older homeless individuals, they try to hold on to their dignity while retaining control over whatever parts of their lives they can. The responses to some around shelters were that they brought less 20 20 dignity than the streets due to the control over their actions and the lack of safety. Eight types of events were found that undermine dignity, such as being yelled at or insulted by staff persons and having staff use rules excessively and arbitrarily. The results suggest that dignity is an important variable to consider in understanding the experience of homelessness. Policies and programs that support validating the dignity of homeless persons are encouraged (Miller & Keys, 2001). Homeless persons often lack roles, occupations, or social relationships that will allow them to contribute and feel like worthy members of society. The purpose of the solution is to serve as many as 10-12 clients a day by transporting them to healthcare programs, providing pharmacy assistance, and meeting their daily needs to build stability. The organization has a van and has already started transporting clients to receive healthcare, connecting them to employment tools and therapy sessions, bringing outreach resources to them, and providing hygiene necessities. There is a weekly schedule and consistent communication between Grace Within Transition’s staff and clients. Each client has been seen by a doctor and was able to collect their medications within the same week at the pharmacy. Certain clients require follow-up appointments at the Urban Ministries facility to address ongoing health concerns. However, in Raleigh, NC, the lack of transportation poses a significant obstacle, preventing clients from reaching crucial organizations that provide various necessary resources. Clients consent to transportation services for accessing care to establish trust and engagement. The organization collects daily data to monitor client progress and their efforts’ overall effectiveness. The optimal approach is to meet clients where they are, considering many lack awareness of available services and opportunities. Removing these barriers can significantly enhance access to assistance for homelessness. 21 21 Solution Landscape The proposed solution builds on relevant policies, programs, models, initiatives, services, and processes. Solving homelessness for adults requires new commitments of resources, new partnerships, and scaling up programs that have shown promise to work. One intervention is the SSI outreach, which aims to increase the income of these individuals and provide them with a stable income stream. Another program, SOAR, assists in applying for social security disability and supplemental income. The SOAR program has successfully helped more than 45,137 people obtain benefits by bringing case managers and stakeholders together to coordinate implementations at the state and local levels (SAMHSA, 2022). Older individuals experiencing homelessness for the first time may be unfamiliar with the necessary steps or actions to take. A homeless prevention program called “Housing Advice” focuses on various topics, including landlord-tenant mediation, emergency cash assistance, case management, and debt relief. Another existing solution in NYC is the Mobile Crisis Teams, consisting of behavioral health professionals such as social workers, peer specialists, and family peer advocates. These teams offer care and short-term management for individuals experiencing severe behavioral crises, providing services directly in the community. The goal is to ensure mental health engagement, intervention, and support to help people stay connected with their treatment providers. If a Mobile Crisis Team determines that an individual requires further psychiatric assistance, they can arrange for the person to be taken to a hospital psychiatric emergency room. Another service available to the adult homeless population is HUD rapid rehousing for those who do not self-resolve with housing advice. Homeless individuals with a disability may be eligible for potential funding through Medicaid to receive rehousing assistance. A model based on evidence-based behavioral health intervention can aid their recovery or rehabilitation 22 22 (Culhane & Byrne, 2019). Furthermore, there are housing support and assisted living options to help them maintain independence and avoid nursing home placement. These programs are eligible for reimbursement from Medicaid. All these implemented strategies would require advocacy to put political and organizational alliances in place for successful implementation. Housing First provides permanent independent housing for chronically homeless older adults and includes supportive services related to mental health disabilities or substance abuse disorders. It is an approach to providing permanent housing and can help individuals pursue personal goals to improve their quality of life. The idea is that older homeless individuals need necessities like a place to stay and food before they can tackle things such as finding a job, learning to budget, and more. One added factor is that Housing First allows them to exercise their choice to participate in supportive services. Housing First boasts an impressive long-term retention rate of up to 98% and proves highly effective in swiftly transitioning individuals out of homelessness within two months, ensuring they remain housed (Montgomery, 2013). The Substance Abuse and Mental Health Services Administration (SAMHSA) organization plays a vital role in providing a wide range of services for the homeless, encompassing outreach, case management, multiple treatments, peer support services, insurance programs, and employment readiness access. Their primary focus is on chronic homelessness, and statistics from the Office of National Drug Control Policy reveal that 30% of the chronically homeless population suffers from severe mental illness, with two- thirds of this group also experiencing chronic health conditions. There are several transportation models around the world in San Diego (Travelers AIDS Society Program), New York (Captain Community Human Services), and Kansas City (Hope 23 23 Faith) that provide mobilized transportation and services to the homeless population. They come out to the community to assist with medical needs through outreach workers. This approach helps reduce barriers between the homeless, low-income, and social service agencies. There is no fee for transportation and services for homeless people aged eighteen and older. These programs have been shown to reduce the amount of time someone experiences homelessness (About, 2022). In Raleigh, North Carolina, no transportation services are available because organizations are unwilling to come out to the communities and work directly with the homeless population. Consequently, individuals can only receive services if they go to a specific facility. Unfortunately, Raleigh has only a limited number of one-stop-shop organizations which do not provide transportation assistance. The only available transportation option is the city bus, but even after reaching their stop, clients may still need to travel a few more miles to reach their destination. This poses a significant challenge for disabled clients who cannot cover that distance. Prototype Description This project involves the construction of a bridge for homeless individuals, achieved through outreach and a linkage program. This service proves immensely beneficial for chronically unhoused adults with untreated medical conditions as it assists in identifying their health concerns and offers transportation and ancillary services to cater to their needs. Ultimately, this comprehensive approach enhances their overall health and wellness, gradually preparing them for a successful transition to housing options. This initiative will connect them to all available resources, granting them a second chance at a healthy and fulfilling life. My prototype will include sanitary needs, urgent and long-term care, and social support services. 24 24 Urban Ministries, one of the largest organizations in Raleigh, North Carolina, will provide resources for persons who are homeless at one location. This approach is vital as it addresses the transportation limitations faced by unhoused adults in Raleigh, allowing them to access the comprehensive services provided by Urban Ministries conveniently. The Urban ministries and WPW organizations provide medications to the disadvantaged. Each organization will provide medical care, mental health services, substance abuse treatment, housing, employment assistance, and medications. The transportation service is an additional component of the prototype. As a member of Divine Restoration Worship Center, Apostle Everton Harris agreed to donate a van from his ministry to transport persons who are homeless to appointments up to three times a week. Thursdays and Saturdays are the slated outreach days. We will begin with two individuals each day for piloting and results purposes. Additional services would include delivering nutritious food, water, hygiene kits, and masks to the community. As shown in Table 1, Grace Within Transitions staff will include volunteer members for multiple roles. It will include two male drivers. One will operate the van, and the other will sit in the rear of the van in case of an emergency. Considering there will be two daily trips, each driver will be responsible for the morning or afternoon journey. Furthermore, the staff will consist of two volunteers onboard the bus, assisting clients with paperwork before transportation and ensuring their seamless handover to the clinics by the staff. We have two volunteer medical assistants willing to assist during transportation in case of any health issues. Both of these medical assistants hold CPR/First aid certifications. Another staff member recently volunteered to join the team, serving as an intern and contributing 40 hours of community work towards her bachelor’s degree. Additionally, we have an 25 25 administrative coordinator among our volunteers who will help with transportation pick-up and drop-off while managing medical scheduling. Our team consists of 11 volunteers, two main drivers, two medical assistants with CPR/First Aid certifications, two CPR/First Aid instructors, an administrative coordinator, one intern for additional support if needed, and four general volunteers. All of our volunteers will actively participate in transportation and outreach activities as part of their roles, as outlined in Table 1. Table 1 Grace Within Transitions Organization Staff Members Volunteer Member Role Tanasia Futrell Outreach/Van Attendee Jaquari Futrell Extra Driver/Van Attendee Dominique Young Outreach Richard Brown Main Driver Juan Brown Extra Driver/Van Attendee Stephanie Sutton Medical Assistance Venice Wynn Administration Coordinator Jade Journigan Medical Assistance/CPR/First AID Shanica Hannah CPR/First Aid/V olunteer Brittany Jones CPR/First Aid/V olunteer Wallace Powell Main Driver Tami Blue Intern/volunteer Specific days are allocated for pick-ups, drop-offs, and outreach services for the homeless. Table 2 illustrates the van schedule for the entire week. Clients of Urban Ministries can access services on Monday from 2-4pm, Tuesday & Wednesday from 2-6pm, and Thursday from 1-4pm. On Fridays, Urban Ministries remain closed as they attend walk-ins during these times. WPW serves clients all day between 9 am to 5 pm. On Monday, Tuesday, Thursday, and Friday mornings from 9 am to 1 pm, five clients will be taken to WPW for assessments and medical care. Around 1:30 pm, five more clients will be transported to WPW in the afternoon, 26 26 and two additional clients will be taken to Urban Ministries. These clients will receive medical care and undergo evaluation based on their needs, after which they will be returned to their respective destinations. Urban Ministries has guidelines that include two walk-ins with confirmation on the morning of the scheduled arrival. If there is no confirmation, the client must set up an appointment. Building rapport is crucial in all aspects of this process. Upon boarding the van, individuals experiencing homelessness will be required to fill out several forms. These include an emergency contact form, a HIPAA form to collect personal information and data, a picture-taking agreement, and a health disclosure form safeguarding their health information. The volunteer staff will oversee the completion of these forms, ensuring they are filled out thoroughly. Clients will be picked up and dropped off consistently at the designated location in front of Taco Bell. Pickups must be scheduled one to two days ahead of time. I have acquired a phone to stay in touch, store contacts, and manage pickup and drop-off times for communication and organizational purposes. Every Wednesday at 9 am, designated as pharmacy day, I accompany the clients to collect their prescriptions. Urban Ministries has its own pharmacy, where they graciously allow me to wait with the clients. WPW is working on establishing a connection with a preferred pharmacy in the vicinity, as they already have a medical doctor to handle treatment. Moreover, in the morning hours, from 9 am to 1 pm, five clients will be transported to WPW. The second trip, from 2 pm to 5 pm, will involve another five clients being transported. Both trips will have Taco Bells on Capital Blvd as their destination. On Saturday, I will conduct outreach, bringing nutritional meals to selected locations in Raleigh. During this outreach day, we will engage in conversations and conduct a prescreen survey to gather data and assess the required services. It is a time when homeless individuals feel 27 27 comfortable sharing their concerns and requests. Some of the requests we received included access to showers or medical assistance. Additionally, some expressed worries as people tended to avoid them out of fear. Another common concern was the need for state IDs. Homeless individuals cannot obtain a free government phone without a state ID, while others have state IDs but lack health insurance. These barriers must be taken into consideration. Access to a phone is crucial for them, especially for handling last-minute changes such as closures or location shifts. Moreover, once connected with an organization, having a phone is essential for follow-ups and maintaining contact. Coordinating appointments and follow-ups will be handled by volunteers and social workers. WPW social workers will distribute their intake forms on Saturdays or a day of their choice. WPW will send social workers who will build a rapport to start working with individuals who are homeless. They will either return the forms to their office for review or upload them to their system electronically. Clients will then be scheduled for transportation to WPW to meet with their social worker, who will conduct a needs assessment. Anyone in need of medical attention may be brought to either WPW or Urban Ministries. In the case that clients are not residents of Wake County, Urban Ministries will direct them to Project Access after the first initial visit. Referrals are mostly restricted to those who are not Wake County residents. WPW partnered with me due to their interest in my mission and desire to assist in bringing homeless individuals off the streets. However, WPW specifically seeks clients with a criminal background. During my data collection, I’ve already encountered several referrals to WPW, and this number keeps growing! Their process involves completing an assessment, followed by a meeting for a needs assessment to initiate the provision of services. Their ultimate aim is to help homeless individuals get back on their feet by accessing employment, housing, and 28 28 more. Divine Restoration Worship Center will be on-site to check blood pressures for the population, thanks to the availability of certified registered nurses who will be working alongside me and other volunteers. These nurses will also educate homeless individuals on disease prevention. Each client will receive a follow-up to gauge their progress, address transportation scheduling, and provide any necessary resources. (See Table 2) Table 2 Weekly Schedule for transporting persons who are homeless to health services/outreach. Day of the Week Schedule Monday AM Pick up: 8:30 am at Taco Bell on Capital Blvd Drop off: WPW (9-1 pm) Occupants: 5 PM Pick up: 1:30 pm at Taco Bell on Capital Blvd. Drop off: Urban Ministries (2-6 pm) Occupants: 2 2 nd Drop off: WPW (2-5 pm) Occupants: 5 Final stop: Taco Bell on Capital Blvd Tuesday AM Pick up: 8:30 am at Taco Bell on Capital Blvd Drop off: WPW (9-1 pm) Occupants: 5 PM Pick up: 1:30 pm at Taco Bell on Capital Drop off: Urban Ministries (2-6 pm) Occupants: 2 2nd Drop off: WPW (2-5 pm) Occupants: 5 Final Stop: Taco Bell on Capital Blvd. Wednesday AM Pick up: 9:00 am Taco Bell on Capital Blvd Drop Off: Pharmacy Day (9-1 pm) WPW (9-1 pm) Occupants: TBD (Based on who needs meds) 5 to WPW Pick up: 1:30 pm Taco Bell on Capital Blvd Drop off: Urban Ministries (2-6 pm) Occupants: 2 Final Stop: Taco Bell Thursday AM Pick up: 8:30 am at Taco Bell on Capital Blvd Drop off: WPW (9-1 pm) Occupants: 5 PM Pick up: 1:30 pm at Taco Bell on Capital Drop off: Urban Ministries (2-6 pm) 29 29 Occupants: 2 2 nd Drop off: WPW (2-5 pm) Occupants: 5 Final stop: Taco Bell on Capital Blvd Friday AM Pick up: 8:30 am at Taco Bell on Capital Blvd Drop off: WPW (9-1 pm) Occupants: 5 PM Pick up: 2 pm at Taco Bell on Capital Drop off: WPW (2-5 pm) Occupants: 5 Final Stop: Taco Bell on Capital Saturday Outreach Day: 1 pm • Volunteer interns, Divine Restoration W orship Center, and I will deliver nutritious food and beverages to the communities. • Share information about available services. • Volunteers, T wo Nurses, Social W orkers, and I will gather at a designated location in Raleigh. • Conduct surveys. • Complete the assessment process by WPW Social workers. • Schedule transportation appointments for the following week. • Two nurses will provide health education on disease prevention. • Distribute Hygiene Kits. • Perform Blood Pressure checks. • Follow up with clients for check-ins. The outreach will receive backing from a team of volunteers consisting of two nurses from my ministry and several social workers from the WPW program. These dedicated individuals will be responsible for educating the clients on various health matters. We’ll be tracking their valuable information and feedback through surveys. DRWC (Divine Restoration Worship Center) will pray with the clients, offer them access to relevant resources, and distribute hot and cold meals and beverages. Additionally, the ministry will provide hygiene kits that include masks, sanitizers, soap, and other incidentals. We frequently visit the same downtown Raleigh location for outreach day and have built a strong rapport with the individuals there. The ultimate goal is to help more homeless individuals find housing. To achieve this, I provide them with housing applications and offer assistance in completing and submitting them for review. 30 30 In addition to the outreach, my prototype will include a training and preparation guide for the personnel involved. Anyone assisting with the outreach will have access to a training manual (See Appendix D) containing frequently asked questions and their respective answers. The manual will address inquiries related to obtaining a state ID, birth certificate, proof of residence, social security card, green card, and techniques for building rapport, fostering understanding, and engaging people effectively throughout the process. This manual will serve as a valuable resource for the outreach volunteers. Everyone must acknowledge their role as bridge builders and translators, advocating for the disadvantaged. I plan to explore my project further to determine how this approach can help homeless individuals access medical care, housing, employment, and mental health services. The goal is to grow and increase the number of clients each day. Additionally, as the prototype expands, there will be a need to obtain a second van to reach more homeless individuals. The likelihood of success involves serving over 60 clients per month, expanding transportation services from one to two vans to accommodate more daily pickups, and enhancing the access and quality of healthcare for chronically homeless individuals. Reducing the number of no-shows to appointments, increasing Medicaid recipients, and expanding outreach services are crucial objectives. Consequently, providing more services will lead to long-term stability, including housing or employment. 31 31 Methodology This project was created to promote engagement, satisfaction, and solutions using a design criteria model. The model encompasses empathizing with chosen users, analyzing and addressing the issues at hand, ideating, prototyping, and testing the project. Questionnaires were employed to engage homeless adults with chronic conditions to identify healthcare as a pressing concern. Outreach volunteers visited the communities to seek potential clients’ permission for data gathering. After extensive research and interviews, a solution was developed to address the lack of resources, healthcare, and transportation accessible to adult homeless individuals. Over time, the project attracted more volunteers and established partnerships with organizations sharing similar missions, leading to the initiation of pilot programs daily. The assessment process collects health issues, stability status, and family information. Each client has access to an outreach worker, social worker, case manager, and healthcare provider. Some important information includes a list of organizations offering resources, the van schedule for transportation to healthcare or medical clinics, and details about outreach events, which will be consistently explained. Surveys will be provided at specific intervals to monitor the progress of the clients. Rules are in place, and all services are provided free of charge. Clients will start receiving benefits such as Medicaid, SSI, or SSD if needed. The project’s financial plan involves completing the Grace Within Transitions process of obtaining the 501c3 status, which is currently in progress. Once this step is finalized, Council Member Stormy Forte from Raleigh, NC, will be able to include the organization in a grant list, increasing the chances of receiving a grant through the Wake County Continuum of Care. I have been advised to participate in the COC because its purpose in Raleigh, NC, is to collaborate with the community to effectively plan and manage homeless assistance resources and programs to 32 32 end homelessness. Additionally, I will be starting a grant writing class at Wake Technical Community College to enhance my skills in this area. Furthermore, I have established communication with several doctors who have knowledge about obtaining grants. They have kindly allowed me to attend their monthly grant meetings for non-organization programs. Another valuable partner is the DRWC, which has already begun collecting donations during weekly services. Moreover, they have graciously offered their establishment to host fundraising outreach events on the organization’s behalf. The project’s method to measure outcomes around the impacts of social change will be done using a pre and post-test table, assessments, surveys, PHQ2, and sign-in sheets for transportation services. This will detail the characteristics of the clients, how many clients have used the transportation services, the causes of homelessness, the number of appointments completed, and the client’s progress from start to finish. Other outcome measures include increasing access to Medicaid, state ID, doctor visits, dentist appointments, referral to other services, and reduction of depression through transportation services. According to Table 3, unhoused adults over 21 years lacked many health resources, and social services needs until they received access to transportation. Once the unhoused adult became a client, the outcome measures changed for the better. Out of 75 unhoused adults, the number of missed appointments decreased from 75 to 35. There is an increase in visits to the dentist and transportation rides. Unhoused adults were at the rate of 65 who did not have Medicaid; however, with transportation and outreach, that number decreased by 10 clients. 33 33 Table 3 Outcome Measures Unhoused Adults Demographics Pretest Posttest after 1 month Age (21+) 75 75 Gender Female 43 43 Male 32 32 Transgender 0 0 Gender Non-conforming 0 0 Race White 22 22 Black or African American 46 46 Native American 0 0 Multiple Race 0 0 Unhoused Adults Questionnaire No Medicaid 65 55 No State ID 45 55 Has Health Issues Yes Yes No Doctor Visit 64 32 No Dentist Visit 70 45 Current Health Needs 75 70 PHQ2 60 43 Missed Appointments 75 35 Referral Access to Services 73 56 No Transportation 72 60 Grace Within Transitions has weekly meetings with all staff and monthly board member meetings to discuss progress and upcoming tasks. The project’s plan intends to involve stakeholders through presentations, interviews, and short videos explaining the goals and the purpose of the innovation. This approach has opened doors for networking and forming partnerships with entities interested in supporting the vulnerable homeless community. Effective communication products utilized in the project include meetings with leaders or directors of organizations, providing significant advantages for the organization. Engaging in one-on-one or 34 34 group settings plays a major role in bringing everyone together and receiving valuable feedback from partnered organizations and mentors, who are instrumental in the project’s development. Implementation Plan The multi-layered framework comprises several components, including four phases and the outer and inner organizational contexts that can influence implementation (Moullin et al., 2019). The Framework consists of Exploration, Preparation, Implementation, and Sustainment. In the exploration phase, the problem was identified and communicated to staff planners and stakeholders, who agreed to collaborate with Grace Within Transitions. They acknowledge the public health necessity and have explored ways to address the issue. The subsequent phase is preparation, during which barriers and facilitators are identified. Notably, adult homeless individuals face challenges in accessing healthcare services, mental illness treatment, health insurance, and addressing issues related to drug and alcohol use, domestic violence, and chronic health conditions. 73% of respondents reported at least one unmet health need, such as the inability to access necessary medical or surgical care (32%), prescription medications (36%), and mental health care (Baggett et al., 2010). These individuals struggle to navigate the public welfare system and lack guidance for completing forms, making appointments, or attending examinations. Adult homeless individuals often face challenges utilizing mainstream services that require regular communication with agencies, services, and transportation. Moreover, they lack a permanent address or phone number, making completing paperwork and accessing services difficult. One facilitator is deploying outreach workers within the community, which has proven instrumental in bringing about necessary changes in the attitudes and behaviors of the clients. These outreach workers will undergo comprehensive training to ensure their proficiency in 35 35 fostering high levels of social engagement and establishing stronger connections to the external environment. They will actively participate in the critical initial stage and contribute to formulating coordination and intervention strategies. While working with the adult homeless population, outreach workers should be cautious of their actions and bear in mind that their expectations may not always align with each individual’s struggles. They should be honest about their limitations. There is a need for them to establish supportive relationships within the community, offer advice, and connect those who are disconnected from mainstream and targeted services. Building strong relationships is crucial because there are legitimate barriers that hinder them from accessing necessary services. Dignity is defined as self-worth or inner worth. Recognizing someone’s dignity is acknowledging their value as a human being, irrespective of their status or role in society (Berger & Kellner, 1974). The process takes time as it involves understanding their circumstances and needs. The ultimate goal is to help them transition off the streets as swiftly as possible. Outreach workers are crucially required to assist those who are difficult to locate, whether unhoused or housed. Many homeless individuals avoid shelters for various reasons, including fear, the inability to bring their pets, and a desire to maintain relationships formed while living on the streets. During the implementation phase, staff members were identified, and partnerships were established. One notable partnership was with DRWC, which generously donated a van for the pilot program and continued using it to serve people experiencing homelessness. The next steps involved creating schedules for the van to transport up to two clients daily to medical and healthcare services. Additionally, the organization was in the process of becoming an official nonprofit organization. Much of the funding has come from donations received from churches and fundraisers. 36 36 In the last phase of sustainment, there are continuous changes and expansions. Additional services will be implemented, such as clothing donations and new contacts to assist with the funding process, marketing, employment, and implementing transitional housing, among others. The transportation service has increased the number of clients picked up by making two trips. The most recent fundraiser enabled the purchase of organizational t-shirts for staff to wear while out in the community. Clients will be dropped off at Urban Ministries and the WPW program to access the necessary services. The project’s start-up budget for the year is $100,000, which includes cleaning maintenance, oil changes, mechanic use, van insurance, 2-3 hourly employees, and outreach. Eventually, an accountant will also be needed as the organization expands. The organization has had two board meetings in the last two months, during which members were voted in, and the roles of each member were determined. Challenges One contributing factor to the ongoing problem is insufficient effective solutions to meet the demand. Not everyone in every community has taken responsibility for providing services to those experiencing homelessness. Resolving homelessness requires a systemic approach that prioritizes equity, examines policy decisions based on accurate and up-to-date data, and fosters collaboration at the state, federal, and local levels. There is a need to provide a broad range of supportive services such as mental health, substance abuse treatment, employment, education, childcare support, and transportation. We all should be more humane when it comes to society. Some of the challenges are evident within the contingency plan that has been implemented to ensure the continued success of the prototype when changes arise. (See Table 3). 37 37 Table 4: Contingency Plan Contingency Plan What If I am sick? There are five experienced drivers who can assist with transporting the clients. What if someone acts out on the van and threatens others? Two men will be on board: one driver operating the van, one in the rear, and one volunteer riding along. Additionally, two volunteer medical assistants will be present. The van will be stopped at a secure location, and authorities will be notified to ensure the safe removal of the individual from the van. What if no one wants to go on a specific day? Rescheduling is available and will be coordinated accordingly. Clients should contact the day before the pickup day if they want to cancel; however, same-day canceling is also available. If they miss their pickup time, they will be able to reschedule by phone or text for the next availability. The grace period for lateness is 15 minutes. What if someone dies in the van? Emergency consent forms are completed prior to anyone boarding the van, ensuring contact information is available in case of an emergency. Please call 911 immediately if an emergency arises. One CPR/First AID/AED Certified volunteer nurse is on board to perform CPR until the authority arrives. Additionally, we have a First Aid Kit readily available for any necessary medical interventions. What if more want to go than the capacity? We keep accurate records of trips for all riders, and pickups are scheduled for a limited number of participants, with explanations provided. Transportation information will be provided to all riders for any questions. Van review The van will be regularly checked to ensure it remains safe to drive, including tires, battery, oil change, inspection, and cleaning. All riders will be required to wear seat belts for their safety. Inside the bus, there will be visible Van Rules for everyone to follow. Additionally, each client will need to complete the HIPPA form. 38 38 It was important to build a strong foundation by setting goals, establishing metrics, designing roles, and facilitating. The next factor is identifying resources that will benefit the users, such as vehicles and equipment, staffing, and planning. Another factor is connecting with partner agencies, local policymakers, law enforcement, and homelessness services. Most of the time, law enforcement encounters lots of people experiencing homelessness, and they are positioned to connect them to the resources they need. This creates room for trust and relationships to divert people from the justice system. Some clients will not want to comply with follow-ups to gain access to care. Ethical Consideration and Applying Design Justice Principles Grace Within Transitions will implement monthly staff training, which will include diversity material. Pamphlets covering protection against discrimination based on race, disability, gender, religion, sexual orientation, age, and socio-economic differences will be shared with clients. The staff members working in these communities, assisting this vulnerable population, often experience extreme poverty, challenging their skills and knowledge. They are encouraged to approach their work with dignity, non-judgmental attitudes, and empathy while adhering to ethical and moral principles. Some participants have acknowledged that not many people are willing to help or engage in conversation with them. They expressed that those who claimed to offer assistance often failed to remain consistent, merely selling them a dream without following up. It is crucial to work with the homeless population voluntarily and informally, ensuring they understand the implications of their participation. All voices from the communities are essential for gathering information. In conclusion, Grace Within Transitions does not pose any harm to the adult homeless population. 39 39 The purpose of Grace Within Transitions is to establish a sustainable organization that continuously empowers communities. We prioritize listening to the voices directly impacted by their circumstances, addressing the lack of food, shelter, healthcare, and hygiene. Focusing on clients’ barriers enables them to develop skills, resources, and stability. As the project designer, being a leader is not enough; a consistent team is essential to carry out the organization’s mission and values. Helping one individual through regaining housing encourages more people to participate. Maintaining engagement with the community has a significant impact, as it demonstrates that they are an integral part of the team, working to help themselves and others. Conclusion and Implications As mentioned in previous papers, the Grace Within Transitions organization found building this prototype exciting and nerve-wracking, given the unknown challenges in pursuing a long-held passion. Engaging with older individuals experiencing chronic homelessness was stepping outside their comfort zone. There was some hesitation in hearing about the difficulties faced by chronically homeless adults after such a prolonged lack of help. Understandably, there will be challenges in reintegrating into society as a formerly homeless person. However, there was also a sense of urgency and excitement in meeting the local target group and learning about their needs. Our culture has often overlooked the fact that homelessness is a problem affecting everyone, and we are often just one step away from such a situation. It is important to recognize that not all homeless individuals are alcoholics or drug addicts, as society sometimes characterizes them. Having spoken to numerous community members, it is clear that they worry about potential outbursts, stares, and misunderstandings from homeless individuals. However, they also believe these individuals deserve a second chance, and listening to their stories has motivated a 40 40 desire to offer support and advocate. Society should strive to bridge the health gap, as many individuals have not seen a doctor in years. Basic human requirements are rights everyone should have access to, yet society continues to fall short of meeting this reasonable goal. The prototype emphasizes community outreach and connectivity through physical interaction. Raleigh, North Carolina, requires this prototype for various reasons, as its government lags behind northern states like New York. The concept begins with visiting communities to establish relationships and collect basic information and needs through questionnaires. Additionally, they will be provided with meals and hygiene kits, accompanied to clinics and pharmacies for medical treatment and medications, and then returned to their drop-off points. The goals are to build trust, rapport, and connections. Finding accommodation, food, healthcare, and employment becomes challenging without proper medical treatment. There have been positive and negative aspects throughout the entire process of creating the prototype and preparing for the pilot test. Conversations with numerous Raleigh stakeholders, organizations, and influential individuals have provided valuable insights into the problems. As a result of the lifting of COVID restrictions, several other changes have occurred. Notably, the free Snap benefits for food assistance have been discontinued, and there has been a decision to expand Medicaid, contrary to its initially planned reduction. If Medicaid is not expanded, there will be an increase in the number of beneficiaries without health insurance. Urban Ministries stands out as one of the most effective organizations for assisting destitute adults. The organization provides support to adults in dire circumstances, offering help with food, shelter, basic hygiene, medical care, and other essential needs, all under one roof. However, senior individuals are responsible for completing the necessary steps to access these services. Challenges may arise for adults who need to join Project Access but do not reside in 41 41 Wake County, as they will require a referral. This is the process through which referrals are obtained for Project Access. Although buses run in the direction of the organization, clients will have to walk a mile or two to reach it. Urban ministries lack transportation facilities and have explicitly stated that they do not provide taxi services due to well-known challenges. They did mention that anyone can visit their walk-in clinic, but the next step would be to get their prescription from a pharmacy. If the pharmacy clinic is unable to dispense their medication, Grace Within Transitions will arrange transportation to the pharmacy. In Raleigh, NC, no organizations have incorporated transportation services into their setup. The largest organization, Urban Ministries, has acknowledged the need for transportation and is actively seeking grants to assist them in this regard. This project can expand beyond Raleigh to other cities and counties by placing vans in different locations, collaborating with other organizations, and organizing outreach days to promote their services. Gathering data through completed questionnaires will be crucial on a county, city, and state level to understand the population’s needs. Halting the progression or spread of diseases, providing necessary services such as medications, and gaining access to health insurance will assist homeless, elderly individuals who suffer from chronic health conditions. This approach seeks to foster a sense of respect and humanize those who spend nights in their cars or on the streets, as anyone can unexpectedly find themselves in such circumstances. Every day, we pass by several individuals who were once affluent and in stable positions but are now homeless. It remains crucial to continually raise awareness and advocate for increased support for people experiencing homelessness in your community. The objective is to transform people’s perceptions of homelessness and foster the realization that even those living in extreme poverty are human beings deserving of empathy. 42 42 Our nation must prioritize addressing the needs of both housed and unhoused individuals. As time progresses, further discussions and inquiries will undoubtedly arise regarding the ongoing homelessness situation. Overall, the population of persons experiencing homelessness represents a neglected and disregarded group that continues to have unmet needs or barriers when accessing healthcare every day. Although the homeless population is a vulnerable group, their life situations and diverse needs lead to assumptions that they would benefit from specific methods in providing health and mental health care services. Next steps, I will continue to provide transportation for people experiencing homelessness to health and medical clinics, plan outreach events, and get my organization up and running. The logo has been created with the mission and values statement. Grace Within Transitions’ long-term goal is to expand services out of state and collaborate with other organizations that lack transportation services. Another long-term goal is to one day implement street medicine, as recently discussed in a meeting with a CEO in California who has been doing this work for many years. This would be necessary here in North Carolina. Additionally, I will create a brochure that will include the services to share with the team and stakeholders. The brochure will be used at outreach events and during transportation services. A point person has been collecting clothing donations for our next outreach event, where we will also be feeding people experiencing homelessness and sharing resources. I have been in contact with a few individuals who are willing to donate to my innovation project to purchase hygiene kits. Most recently, a barber shop here in Raleigh reached out and agreed to provide haircuts to the unhoused on Mondays. Currently, we are only receiving donations to keep the implementation plan going. Divine Restoration Worship Center has weekly collection 43 43 plate donations to go towards the organization, and once biweekly, a fundraiser is set up after services are completed on Sundays. Recently, the van was inspected for maintenance purposes to ensure it was safe to drive, including an oil change, brake check, and air conditioner inspection due to the weather. The 501c3 process is in progress; however, the implementation planning has already started. (See Appendix C). 44 44 References About. (2022). HopeFaithKC. https://www.hopefaith.org/about-1 Baggett, T. P., O’Connell, J. J., Singer, D. E., & Rigotti, N. A. (2010). The unmet health care needs of homeless adults: a national study. American journal of public health, 100(7), 1326–1333. https://doi.org/10.2105/AJPH.2009.180109 Bassett, E., Tremoulet, A., & Moe, A. (2013). Relocation of homeless people from ODOT rights-of-way. U.S. Department of Transportation, Portland, OR: Transportation Research and Education Center. https://pdxscholar.library.pdx.edu/trec_reports/73/ Berger, P. L., Berger, B., & Kellner, H. (1974). The homeless mind. New York: Vintage Books Brown, R. T., et al. 2012. “Geriatric Syndromes in Older Homeless Adults.” Journal of General Internal Medicine, 27(1): 16–22. Brown, R., Evans, J., Valle, K., Guzman, D., Chen, Y.-H., & Kushel, M. (2022). Factors associated with mortality among homeless older adults in California: The HOPE HOME Study. JAMA Internal Medicine. Advance online publication. https://ldi.upenn.edu/our- work/research-updates/the-older-middle-aged-homeless-population-is-growing-and- dying-at-high-rates/ Burns, V., Kwan , C., & Walsh, C. A. (2020). Co-producing knowledge through documentary film: A community-based participatory study with older adults with homeless histories. Journal of Social Work Education, 56, S119-S130. Culhane, D., Doran, K., Schretzman, M., Johns, E., Treglia, D., & Byrne, T. et al. (2019). The emerging crisis of Aged Homelessness in the U.S.: Could Cost Avoidance in Health Care Fund Housing Solutions? International Journal of Population Data Science, 4(3). https://doi.org/10.23889/ijpds.v4i3.1185 45 45 Henwood, B. F., Wenzel, S., Mangano, P. F., Hombs, M., Padgett, D. K., Byrne, T., Rice, E., Butts, S. C., & Uretsky, M. C. (2015). The grand challenge of ending homelessness (Grand Challenges for Social Work Initiative Working Paper No. 10). Cleveland, OH: American Academy of Social Work and Social Welfare. https://aaswsw.org/wp- content/uploads/2015/04/Ending-Homelessness-GC-4-3-2015-formatted-final.pdf Klop, H. T., Evenblij, K., Gootjes, J., de Veer, A., & Onwuteaka-Philipsen, B. D. (2018). Care avoidance among homeless people and access to care: An interview study among spiritual caregivers, street pastors, homeless outreach workers and formerly homeless people. BMC Public Health, 18(1), 1095. https://doi.org/10.1186/s12889-018-5989-1 Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x Leibler, J. H., Nguyen, D. D., León, C., Gaeta, J. M., & Perez, D. (2017). Personal hygiene practices among urban homeless persons in Boston, MA. International Journal of environmental research and public health. Retrieved September 19, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5580630/ Mcleod, S. (1970, January 1). Albert Bandura’s social learning theory. Bandura’s Social Learning Theory. Retrieved October 26, 2022, from https://www.simplypsychology.org/bandura.html Miller, A. B., & Keys, C. B. (2001). Understanding dignity in the lives of homeless persons. American Journal of community psychology, 29(2), 331–354. https://doi.org/10.1023/A:1010399218126 46 46 Montgomery, A. E., Hill, L. L., Kane, V., & Culhane, D. P. (2013). Housing chronically homeless veterans: Evaluating the efficacy of a housing first approach to HUD-VASH. Journal of Community Psychology, 41(4), 505–514. https://doi.org/10.1002/jcop.21554 Moullin, J.C., Dickson, K.S., Stadnick, N.A. (2019) et al. Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Implementation Sci 14, 1 https://doi.org/10.1186/s13012-018-0842-6 National Alliance to End Homelessness. (2021, August 16). State of Homelessness: 2021 Edition. Retrieved from https://endhomelessness.org/homelessness-in- america/homelessness-statistics/state-of-homelessness-2021/ People, I. (2022). Health problem of homeless people. Retrieved July 24, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK218236/ Plescia, M., Watts, G. R., Neibacher, S., & Strelnick, H. (1997). A multidisciplinary health care outreach team to the homeless: 10-year experience of the Montefiore Care for the Homeless Team. Family & Community Health, 20(2), 58–69. https://doi.org/10.1097/00003727-199707000-00008 Purkey, E., MacKenzie, M (2019). Experience of healthcare among the homeless and vulnerably housed a qualitative study: opportunities for equity-oriented health care. Int J Equity Health 18, 101 https://doi.org/10.1186/s12939-019-1004-4 Roller, Z. (2020). Blog. Providing Water and Sanitation Access to Unhoused Populations during the COVID-19 and Beyond: Guidance for Water and Wastewater Utilities. US Water Alliance. Retrieved September 19, 2022, from http://uswateralliance.org/resources/blog/providing-water-and-sanitation-access- unhoused-populations-during-covid-19-and-beyond 47 47 SAMHSA (2022). Empowering change: Motivational interviewing. (n.d.). Retrieved October 28, 2022, from https://www.samhsa.gov/homelessness-programs-resources/hpr- resources/empowering-change Samuels, M. (2016). Sanitation as a basic human right. SPH Sanitation as a Basic Human Right Comments. Retrieved September 8, 2022, from https://www.bu.edu/sph/news/articles/2016/serving-up-dignity-with-showers Sandham, M. H., Hedgecock, E., Hocaoglu, M., Palmer, C., Jarden, R. J., Narayanan, A., & Siegert, R. J. (2022). Strengthening Community End-of-Life Care through Implementing Measurement-Based Palliative Care. International Journal of Environmental Research and Public Health, 19(13), 7747. https://doi.org/10.3390/ijerph19137747 Smelser N. (1994) Sociology: Per. with English. - Moscow: Phoenix. - 688 p. Stafford, A., & Wood, L. (2017). Tackling Health Disparities for people who are homeless? start with social determinants. International Journal of Environmental Research and Public Health. Retrieved September 19, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750953/ Sutherland, H., Ali, M., & Rosenoff, E. (2022). Individuals Experiencing Homelessness are Likely to have Medical Conditions Associated with Severe Illness from COVID-19 Issue Brief. Office of the Assistant Secretary for Planning and Evaluation. Retrieved July 26, 2022, from https://aspe.hhs.gov/reports/individuals-experiencing-homelessness-are- likely-have-medical-conditions-associated-severe-illness-0. Tulane University School of Public Health and Tropical Medicine. (2021). How do mobile health clinics improve access to health care. Online Public Health & Healthcare 48 48 Administration Degrees. Retrieved October 28, 2022, from https://publichealth.tulane.edu/blog/mobile-health-clinics/ United States Interagency Council on Homelessness (USICH). (2020). Homeless in North Carolina Statistics 2019. Homeless Estimation by State. U.S. Interagency Council on Homelessness. https://www.usich.gov/homelessness-statistics/nc/ Wiewel, B., & Hernandez, L. (2021). Traumatic stress and homelessness: A review of the literature for Practitioners. Clinical Social Work Journal, 50(2), 218–230. https://doi.org/10.1007/s10615-021-00824-w 49 49 Appendices Appendix A: Logic Model Logic Model Program: Grace Within Transitions Organization (Linkage Program) Goal: Bridging the health gap for chronic adults who are homeless without access to services needed to stabilize INPUTS OUTPUTS Activities OUTCOMES What we invest What we do Who we reach Why this project: short term results • Staff • Volunteers • Partnership • Van • Supplies • Location • Research Findings • Community feedback • Training • Marketing and Outreach • Translation services • Patient Health Questionnaire/ Surveys to measure the wellness, Health, demographics of adult homelessness. • Conduct staff meetings • Outreach Workers placed in the communities • Transport clients to healthcare appointments/pharmacy • Connect adult homeless to basic needs & mental/substance health services • Food donations • Hygiene Kits • Housing assistance • Clothing • donations • Vulnerable adult chronic homeless clients • Similar organizations • Community leaders • Decision makers • Public • Awareness • Build dignity • Will give access to medical care, basic needs & prevent the spread of diseases • Increased homeless participants to gain health insurance and health care • Increase access to transportation • Increase attendance at doctor’s appointment for primary and specialist care • Increase stability 50 50 Appendix B: Design Criteria DESIGN CRITERIA CATEGORY DETAILED CRITERIA CRITERIA ANALYSIS Is there are overarching label that can be applied to the criteria (e.g. Equity, Access, Affordability, Compliance) Your categories should reflect overall design mandates/objectives “A good solution must be/do…” What is the specific criteria? How would we know an overarching label had been fulfilled? What does this criteria mean? Your criteria should explain what the category criteria means in the context of your project. It should also reflect the key outcomes your project must produce, the constraints it must meet, and any required attributes. Does your project meet/not meet this criteria? Why/Why not? The proposed design should meet the design criteria. In rare instances, it may not be possible to achieve all criteria, in which case the tradeoffs should be explored and the justifications should establish why this design is ultimately the best possible approach. Facilitate self- direction/determination The beneficiary and user will gain easier access to available services within the communities. There should be tools and inspiration for them to gain independence to services. Should be able to aid with homeless older adults with health issues lacking basic needs, resources, and healthcare. Provide resources and contacts and follow-up weekly. Project meets these criteria after the assessment process, individuals background, health issues, identification and family info. Information is shared throughout the process and will be easy access to clients. Options will be explained and by choice will be assigned too Maintain personal connections Provide a way for beneficiaries to have easier access to case managers personally and assist with sustaining consistent connections with case manager via phone or in person. Clients are provided with an outreach worker, case manager and health worker. Case managers are to help through the process and meet the needs of the user Clients will continue to be followed for progress making sure needs are met to sustain stability weekly. The program must be simply worded and accessible The design must be available to adult chronic homeless population with health issues related to their various mental health circumstances. The supports of services and shelter programs must provide users with all necessary contacts. Should provide a listing of organizations that support programs that can help homeless adults gain health care to get the proper meds. Information is explained to clients on the levels they will benefit from. Provide listing of organizations and medical clinics to follow up on and update on where there at and what the plan is. It must have a way of keep information current Program information of enrollment, client progress should be current and design should provide an easy strategy of surveys, intakes and electronically keeping information shared with and without individuals. Surveys are provided on a consistent basis in order to collect data from clients individually and grouped Must promote equity Promoting systems change to improve equity Policies and rules are put in place Will not diagnose or determine eligibility for services Any homeless older adult is eligible for services who needs it. Clients will be assessed and provided with all necessary benefits Will not substitute for service coordinator/advocates Outreach Workers, social workers and case managers will be accessible Information will be provided in the beginning and throughout the process on paper, website, and word of mouth (outreach). Affordability All Beneficiaries and users will gain access to resources who are homeless at no charge. All clients will be able to be obtaining any services needed for free. 51 51 Appendix C: Action Plan Name: Tamara Young Capstone Project: Bridging the Health Gap for Chronic Adults Who Are Homeless Action/Goal Start Date End Date Status Resource Needs Barriers/Challenges Notes Create budget April 2023 April 2024 Ongoing Transportation Vân maintenance, monthly/yearly, hourly rate for staff, tablets, phones outreach, marketing products Budget will need to cover all expenses and be sustainable. Completing 501c3 to obtain grants Budget will need to be realistic, and salary fit the needs of the staff. Line items created for the budget. Create Job Description May 2023 August 2023 Ongoing Incorporate schedules, trainings, skills, and other components that relate to coordination and direction Finding individuals who are knowledgeable compatible and dependable to engage with homelessness Job descriptions are in progress as well as applications and business header Network and partnership opportunities January 2023 January 2024 Ongoing Create network and engagement who would invest to help build up the resources. Partner with other organizations that share similar views Not all organizations will be on board base on certain policies and agreements Urban Ministries WPW, and Devine Restoration Worship Center have confirmed partnership. Other contacts included Create a schedule for pilot mobile and find location April 2023 May 2023 Ongoing Data to target the most vulnerable communities. Primary location for pickup and drop off Some have phones and some do not to communicate, may not want to ride, violence can occur Create a calendar manually and electronically for staff to follow. Pass out flyers and have outreach workers read 52 52 them to those who are unable to in the community Evaluation May 2023 May 2024 Ongoing Create evaluation via tablets or forms to capture how many and who are receiving services. Keep Logs and Questionnaires Having to rely on certain technologies that will need the best reception/connection and service data Create report that will capture all data collected and make sure to be able to easily read for stakeholders, investors etc. 53 53 Appendix D: Budget Template SOWK725cBudgetTemplate-TamaraYoung 54 54 Appendix E: Collaboration Contacts /Letters Divine Restoration Worship Center National Headquarters – Garner, North Carolina – The United States of America- Apostolic SEE Apostle Everton Harris – Senior Pastor/ Founder March 24, 2023 To Whom This May Concern, My name is Apostle Everton Harris, and I am the Senior Pastor of Divine RestoraJon Worship Center, located in Garner, NC. One of the goals of our ministry is to give back to the community and to help those who are homeless by bringing them equate supplies that they need to just make it day by day. We are aware of the challenges facing persons who are homeless and the potenJal impact on the community at large. We are determined to live out our church moVo “Leading People to Christ, While Restoring Hope to Their Purpose.” By any means necessary. No maVer of their current state of condiJon. This leVer is to inform you that Divine RestoraJon Outreach Ministry has partnered with Ms. Tamara Young to deliver healthy food, drinks, and clothes to homeless individuals. My ministry will be donaJng a 15- passenger van to Ms. Young, so that she may transport the homeless to and from medical treatment services. For individuals without transportaJon, picking up and drop-offs will occur three to four Jmes each week. As a church we are excited to be called to help and support the vulnerable. With Regards, Apostle Everton Harris Apostle Everton Harris Senior Pastor and Founder of Divine RestoraJon Worship Center 904A 5 th Ave Garner , NC 27529 55 55 Appendix F: Pretreatment Guides P retreatment G uide for Homeless Outreach Ja y S . L e v y , MS W , L IC S W PA T H R e g io n a l M a n a g e r Eliot C om m unit y H um a n S e rv ic e s } Why is it important to understand people’s stories or What is the advantage of thinking in terms of a person’s narrative? } What is pretreatment and its 5 guiding principles of care? } What are some Pretreatment Strategies for promoting engagement and productive dialogue? Jay S. Levy, LICSW 2 56 56 } Outreach takes place at a border that divides one world from another (Rowe, 1999) } We are Interpreters and Bridge Builders: Our Objective is to Utilize Dialogue to Cross Cultural Divides (Levy, 2018) } The Trauma of homelessness and the Process of Transition & Adaptation to challenging environments (Germain & Gitterman, 1980) } Review Old Man Ray’s Narrative – “I am the Night Watchman!” (Levy, 2013, pp. 60-62) } Central Question of Outreach: “How do you help those who are clearly in need, yet communicate no need for help?” (Levy, 2013) Jay S. Levy, LICSW 3 } Pre-Engagement – The goal is to facilitate an initial welcomed communication between outreach staff and person experiencing homelessness (Issues of trust & Safety) } Engagement – The goal is to develop a welcomed ongoing communication between worker and homeless person, while setting appropriate boundaries (Issues of safety, trust, autonomy & the challenge of setting professional boundaries by defining roles) } Contracting – The goal is for the worker and client to establish mutually acceptable objectives for their work (Issues of Autonomy/Control & the challenge of promoting client initiative) (Levy, 1998 & 2010) Jay S. Levy, LICSW 4 57 57 1. Relationship Formation – Promote trust, uphold safety and respect client autonomy, while developing goals (Stages of Engagement include Pre-engagement, Engagement, and Contracting) 2. Common Language Construction – try to understand homeless person’s world by learning meaning of his/her gestures, words, and actions - promoting mutual understanding and jointly defined goals (Levy, 2000) 3. Cultural and Ecological Considerations - Prepare and support homeless person for successful transition and adaptation to new relationships, ideas, services, resources, treatment, housing etc. Jay S. Levy, LICSW 5 4. Facilitate and Support Change – Via Change Model & Motivational Interviewing Principles; Point Out Discrepancies, Explore Ambivalence, Give Voice, Reinforce Healthy Behaviors and Develop Skills, as well as Supports; Stages of Change include Pre-contemplation, Contemplation, Preparation, Action, Maintenance, Relapse (Prochaska, DiClemente, and Norcross, 2006; Miller & Rollnick, 1991) 5. Promote Safety – Utilize Crisis Intervention & Harm Reduction strategies (Baer, Marlatt, & McMahn, 1993); These are opportunities for further work! Jay S. Levy, LICSW 6 58 58 The Challenge to Care: Is to gain entrance into the perspec/ve client world... join and give real op/ons that resonate and build bridges to needed resources and services including treatment and housing! Pretreatment Pathways reaches Client through engagement and goes to Services and resources thru accommoda7on and welcoming strategies. ‘an approach that enhances safety while promoting transition to housing (e.g. Housing First), and/or treatment alternatives through client centered supportive interventions that develop goals and motivation to create positive change’ (Levy, 2000, 2010) Jay S. Levy, LICSW 7 59 59 Appendix G: Training Toolkit Whole-Person Care for People Experiencing Homelessness and Opioid Use Disorder: A Toolkit— Part I: Understanding Homelessness and Opioid Use Disorder, Suppor/ng Recovery, and Best Prac/ces in Whole-Person Care (hhrctraining.org) 60 60 Appendix H: Disclosures Comple(on of this document authorizes the disclosure and/or use of health informa(on about you. Failure to provide all the informa(on requested may invalidate this authoriza(on. Your rights regarding this authoriza(on are included on page two of this authoriza(on. CLIENT INFORMATION Last Name: ________________________ First Name: _____________________ M.I.: ____ DOB: ___/____/____ DISCLOSURE OF HEALTH INFORMATION I hereby authorize (please check only one): ¾ An exchange of informa(on between , Grace Within TransiJons and the below party: ¾ Only for the below party to release informa(on to , Grace Within TransiJons: ¾ Only for Grace Within TransiJons to release informa(on to the below party: ___________________________________________________________________ ________ (Please include address, phone and/or fax number of authorized exchanging party) the following informa5on: Category of Informa/on Type of Informa/on (check only one) (check all that apply) ¾ Date of enrollment ¾ Verifica(on of services ¾ Housing transi(on plan ¾ Only a WriPen Summary of Treatment OR ¾ Only the following records or types of health informa(on: ____________________________ OR 61 61 ¾ Any verbal or wriPen informa(on, not including psychotherapy notes ** Any request for psychotherapy notes must be made on a separate release form. for treatment provided between the dates of: _______________ through _______________. (Depending on nature of this request, this may or may not be Agency’s date of admission.) PURPOSE Purpose of disclosure: ¾ to coordinate care between providers, AND/OR ¾ other:________________________________________________________ ___________ EXPIRATION This Authoriza5on expires: ¾ 30 days aXer the client discharges from Grace Within Transi(ons OR ¾ on the following date or event: _______________________________________________ Grace Within Transi5ons Use Only: ❑ AUTHORIZATION REVOKED! If authorized representa(ve later revokes consent, enter effec(ve date of revoca(on: ____/____/____ SIGNATURE Authorized Representa(ve Signature:_________________________ Date Signed: ___ /___/___ State legal rela(onship of Authorized Representa(ve to the client: _______________________ Witness signature (preferred, not required): ________________________________________ YOUR RIGHTS 62 62 You may refuse to sign this Authoriza(on. Your refusal will not affect your ability to obtain treatment or eligibility for shelter and other benefits. 1 You may inspect or obtain a copy of the health informa(on that you are being asked to allow the use or disclosure of. You may revoke this authoriza5on at any 5me, but you must do so in wri5ng and submit it to Grace Within Transi5ons. Your revoca(on will take effect upon receipt, except to the extent that others have acted in reliance upon this Authoriza(on. You have a right to receive a copy of this authoriza(on. 2 You have the right to request the method of delivery for releasing your protected health informa(on. We take privacy seriously and do all we can to keep this informa(on protected. We want to make sure you understand that even with measures in place to keep informa(on confiden(al; there are risks that others may view your private health informa(on if it is sent via e -mail or other electronic means. Informa(on disclosed pursuant to this authoriza(on could be re -disclosed by the recipient. Such re-disclosure is in some cases not protected by California law and may no longer be protected by federal confiden(ality law (HIPAA). 1 If any of the HIPAA recognized exceptions to this statement applies, then this statement must be changed to describe the consequences to the individual of a refusal to sign the authorization when that covered entity can condition treatment, health plan enrollment, or benefit eligibility on the failure to obtain such authorization. A covered entity is permitted to condition treatment, health plan enrollment or benefit eligibility on the provision of an authorization as follows: (i) to conduct research-related treatment, (ii) to obtain information in connection with a health plan’s eligibility or enrollment determinations relating to the individual or for its underwriting or risk rating determinations, or (iii) to create health information to provide to a third party or for disclosure of the health information to such third party. Under no circumstances, however, may an individual be required to authorize the disclosure of psychotherapy notes. 2 Under HIPAA, the individual must be provided with a copy of the authorization when it has been requested by a covered entity for its own uses and disclosures (see 45 C.F.R. Section 164.508(d)(1), (e)(2)). 63 63 Appendix I: Confidentiality Form Confidentiality Policy It is essential that the confidentiality of Grace Within TransiJon clients be protected. All staff must sign the Grace Within Transitions policy on confidentiality of client information. Procedures Below are outlined the levels of confidentiality to be adhered to within the programs. From Staff to Other Clients If a client makes a disclosure to a staff member in confidence, under no circumstances should that staff member betray that trust by sharing confidential information with another client. If an unusual situation arises in which it seems necessary to give confidential information to a client, it should be discussed with the co-presidents and social worker prior to the sharing of any information. From Staff to Staff It is critical to the philosophy of Grace Within Transitions for communication between team members to be completely open. If a client chooses to confide in a staff member and requests that the information not be shared with other staff members, the staff member should inform the client that we must evaluate the information to determine whether or not the staff persons need to know the information. The client must understand that the staff members will communicate with each other. Each staff member is expected to sign a confidentiality agreement, which is kept in their personnel records. From Outside Sources All information received from outside persons and agencies concerning our clients must remain strictly confidential from both the clients themselves and from any persons outside of Grace Within TransiJon, such as: outside service providers, referring organizations, and all university affiliated sources. NOTE: CONFIDENTIALITY MUST BE BROKEN WHEN AN ADULT IS AT RISK OF DOING HARM TO THEMSELVES OR OTHERS OR IS GRAVELY DISABLED. Recipient of Service: Clients 64 64 Appendix J: Photograph/Video Release Form Release Form for Use of Photograph/Video I, the undersigned, as a recipient of services from _______________ ________________________________________________, do hereby consent and agree as follows: § § ___________________________________its employees, assigns, consultants, designees, or agents have the right to photograph or video me, and to supervise others who may do the photography. These photographs may thereafter be edited/enhanced, and/or otherwise produced for media usage. The original and edited versions will be referred to below as “photographic material.” § The “photographic material” may be used by ______________ only in connection with _______________ to promote _____________project work. § The photographic material may be disseminated and/or reproduced in other media formats by xxx for distribution in xxx brochures, written marketing materials, social media posts, including Twitter, Facebook and others. In addition, the photographic material may be uploaded onto xxxs websites, specifically, located xxxxxx. The website is available to all persons accessing the Internet address. § The photographic material will not be utilized in any other manner by xxx § My name may be utilized in connection with any of the photographs taken. § I transfer to xxx any personal/property rights to the photographic material that may be produced, including the use of my image and likeness, and I agree that all originals and copies of the photograph(s) will become the property of AHP in perpetuity, except as may be provided below. § This Release is intended to be in full compliance with M.G.L. Chapter 214, Section 3A, and I do hereby release to ADVOCATES FOR HUMAN POTENTIAL, INC., its employees, assigns, consultants, designees, or agents, any rights, claims, or interest I may have to control the use of my likeness, portrait or picture, in whatever media used in accordance with the purposes stated in this Release. § I will not have any rights to receive financial or other remuneration or compensation at any time for this participation, the photographs or any materials as produced that may utilize the photographs. § AHP may utilize a professional, or amateur, photographer to take the photographs. In either case, the photographer will have no rights to independent usage or display of the photographs. § AHP has no obligation to utilize my photographic material at any time in any manner. § xxxis not responsible for any expense or liability incurred as a result of my participation in this photography, including medical expenses due to any sickness or injury incurred as a result. I FURTHER ACKNOWLEDGE/AGREE TO THE FOLLOWING: 1. I understand that I am not obligated to participate in this project in any manner. 65 65 2. I may withdraw from participation at anytime during the photography session(s), and request in writing to AHP, within seven (7) days, that the photographs of me thus taken not be used in any manner. 3. I give my permission to AHP to reproduce and use the photographic material as they deem appropriate, for the purposes stated above, subject only to my opportunity of review, as outlined below. 4. If I do not notify AHP in writing within seven (7) days of any objection, then AHP will have all rights to utilize the material as stated above. 5. AHP will maintain records of this consent form, and records that the photography took place. I represent that I have read and understand the above information and am competent to execute this agreement. I have had the opportunity to ask questions about this project and my Consent. By signing below, I voluntarily give my informed consent to participate, and to the use of the photographic material produced as stated above. Signature : ___________________________________________________________ Print Name: ____________________________________________ I agree to be contacted/sent materials at the address/phone number: Address: Phone: Witness: Print Name: _______________________________________ 66 66 Appendix K: Protected Health Information Policy: Grace Within TransiJons complies with legal standards governing the release of Protected Health InformaJon (PHI) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In accordance with HIPAA Privacy Rule 45 CFR § 164.530(b)(1), all staff members will be trained on the policies and procedures with respect to PHI as necessary and appropriate for the individual to carry out their funcJons at Trojan Shelter. Procedure: Training. All Grace Within TransiJons staff are required to receive annual HIPAA compliance training. AddiJonally, administraJve staff who will process requests for releasing PHI to outside parJes and/or enJJes will receive addiJonal training on such processes. All trainings will be documented and stored with other Trojan Shelter documents. The Social Worker Supervisor shall have oversight of all staff’s compliance with training requirements. If a staff member is found to be out of compliance, their supervisor will be noJfied and an immediate plan will be made to get the staff’s training up to date. Releasing Protected Health Informa<on. Releases of protected health informaJon will be processed by trained staff. Once a request for informaJon is obtained, the requestor will be asked to submit the request in wriJng with a valid AuthorizaJon to Use or Disclose Protected Health InformaJon, clearly indicaJng the records or type of informaJon being requested. Grace Within TransiJons upholds a duty to protect the confidenJality and integrity of confidenJal medical informaJon as required by law and professional ethics, thereby operaJng under the minimum necessary rule. Accordingly, the request will be carefully reviewed by the trained staff for validity and it will be determined what records or type of informaJon should be released, if any, based on the purpose of the request. As appropriate, only select informaJon or a summary of treatment will be released, rather than the enJrety of a document. Once the idenJfied informaJon is prepared to be disclosed, the administraJve staff will release the records in one of the following approved methods: 1. Encrypted and password protected email 2. CerJfied mail, requiring a signature for delivery 3. In person pick-up Aier the records are released, Grace Within TransiJon staff. l record the disclosure in the HIPAA AccounJng of Disclosures Log located in the client’s file, as appropriate. 67 67 Appendix L: Emergency Contact Form
Abstract (if available)
Abstract
The challenges of the adult population's health gap can be lessened by constructing a bridge for persons who are homeless through outreach resources, advocacy, and a linkage program within the communities via a transportation van. This proposed project will contribute to addressing the grand challenge of ending homelessness. Even brief periods of homelessness can have serious, long-lasting effects on an individual's well-being and ability to develop personally (chronically homeless, 2021).
As a social worker, it is critical to take individual differences and cultural/ethnic diversity into consideration. According to Stafford & Wood (2017), the homeless population has high rates of health disparities, which can affect their longevity and quality of life as well as strain the healthcare system (e.g., primary care and mental health services). To get people off the streets and into health and social support, it is crucial to develop new service innovations and technologies, as well as policies that support healthcare and affordable housing.
It will be a significant innovation to use my proposed intervention for adults who are chronically homeless. The van will be used to connect people to healthcare services, which include medical, mental health, prescription, and survival resources for the adult homeless population in Raleigh, North Carolina. These services may include, but are not limited to, a range of health examinations and assessments, triage, employment, housing resources, hygiene supplies such as kits provided, pressure taking, nutritional meals, health education, clothing donation, as well as outreach and case management.
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University of Southern California Dissertations and Theses
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Asset Metadata
Creator
Young, Tamara
(author)
Core Title
Bridging the health gap of older individuals who are chronically unhoused
School
Suzanne Dworak-Peck School of Social Work
Degree
Doctor of Social Work
Degree Program
Social Work
Degree Conferral Date
2023-08
Publication Date
08/09/2023
Defense Date
08/08/2023
Publisher
University of Southern California. Libraries
(digital)
Tag
and vulnerable population,chronic homelessness,Community,disparities,health,Health services,OAI-PMH Harvest,research
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Manderscheid, Ronald (
committee chair
)
Creator Email
tamarayo@usc.edu,tamm20011@gmail.com
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-oUC113297746
Unique identifier
UC113297746
Identifier
etd-YoungTamar-12226.pdf (filename)
Legacy Identifier
etd-YoungTamar-12226
Document Type
Capstone project
Rights
Young, Tamara
Internet Media Type
application/pdf
Type
texts
Source
20230809-usctheses-batch-1082
(batch),
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
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Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA
Repository Email
cisadmin@lib.usc.edu
Tags
and vulnerable population
chronic homelessness
disparities