Do Homeless Have Access to Comprehensive Health Care?

Commentary By Brian Davis

Cleveland Health Care for the Homeless has seen an expansion of the services that it offers, but is it fulfilling its purpose of providing health care to homeless people?

One service provider who has worked with the medical outreach team said that the program was in constant turmoil with staff turnovers and a lack of a medical doctor. The provider claimed that the problem goes back to a lack of strong leadership at the helm of CHCH.

John McKinney, director of CHCH said, “We are working to fill the medical director position. Our interim medical director is the head of the primary care for the Cleveland Clinic.” He said that the medical director’s position has never been a full-time position, and exists largely to satisfy state and local certification oversight. McKinney said that Maria Obias oversees the day to day operation of the medical clinics, and she is a full-time staff member.

Regarding the lack of leadership, McKinney said, “We are the agency for health care for homeless folks.” We are the magnet that brings all the services together including pediatrics, nurses, hospitals, and podiatrists.” They operate clinics at 11 different sites in Cleveland including local shelters and meal sites. The clinics are staffed by nurses and sometimes by a doctor.

Homeless people seem to be generally pleased with the services offered by CHCH. The opening of a clinic at the Bishop Cosgrove Center, the area’s largest meal site, has helped many homeless people. In previous years, the Coalition has developed lists of priorities of homeless people, and health care was always among the top five in importance. This year’s survey shows that basic health needs has for the first time slipped out of the list of high priorities. Access to specialized doctors and dentists as well as access to medication has remained on the list of the community’s top priorities.

Ralph Williams, a customer of CHCH, had a typical response when asked to describe CHCH’s services. He said, “It is a tremendous program. I stopped in at 21st and Payne, and this doctor gave me a thorough going overall examination, and that reassured me that I was not going to drop dead tomorrow.”

There were many complaints about the lack of specialized care. A man who wanted to be identified only as Bill said, “Why don’t they have dental care?” He said that he had a cavity, and went to MetroHealth hospital, and they removed his tooth. He complained that it makes it harder to get a job if you show up for an interview minus your teeth.

One area that John McKinney said that he wanted to address was the agency’s ability to provide homeless people a voice in the direction that CHCH takes. “I began what I hope will be a process to review how much input we are receiving (from homeless people),” he said.

Billy, another homeless person, said, “I have medicine that I gotta take… When I go to get it they say that I gotta see their doctor. You see their doctor, and they still don’t give you the damn medicine. Simple as that.” Sam had a similar complaint about his medication for his stomach problems. “The doctor was low down as a dog to me. He could not wait on me. I told him what I needed, and he told me what he was going to give me,” Sam said.

McKinney said, “We do what we can with the very limited funding that we have for health care. Funding is at one half of what I would like to see it to provide the basics.” Cleveland Health Care for the Homeless has most recently applied for expansion of services to fragile populations rather than expanding access to doctors, especially specialists and medicine.

CHCH has recently acquired a facility for its Gathering Place, a safe haven for mentally ill homeless people. After almost two years of searching for a site and many problems with neighborhood groups as well as city regulations, it has located a building, and quietly opened for business. They are not widely advertising the facility. CHCH does does not wish to draw attention to the program, and thus draw the scrutiny of city officials.

McKinney said, “Nobody wants folks who are homeless to have any services where they are. These folks are citizens of Cleveland and should have the right to be somewhere.” He went on to describe the origins of the The Gathering Place which came about as a result of the perceived need for a safe place that this fragile population could call their own. The Gathering Place is a clubhouse style drop in center during the day for the mentally ill, and has some space for residential use.

One customer of the facility was not happy that there was not a person on staff who could certify an individual as eligible for the service. At this time, the Gathering Place relies on Mental Health Services to certify an individual as “officially” mentally ill. Dr. Steve Friedman of Mental Health Services is satisfied with the relationship with CHCH. He sees the certification process to be a level of staffing that the Gathering Place was not prepared to oversee. “I think that it was not the intent to have that level of professional service,” Friedman explained.

Another customer said that he was not happy that there were no grievance procedures. He said, “Sooner or later if you disagree with them, you are no longer welcome to attend.” He pulled out a memo on Gathering Place stationary that said, “Re: Discharge from GP (Gathering Place). You have been discharged from the Gathering Place for inappropriate (sic) behavior toward another GP member.”

McKinney said, “They have to be appropriate for the program. We cannot tolerate or enable people to violate the rules. Our rate of barring does not exceed those of non-homeless programs for the mentally ill.” McKinney deferred to the Mental Health Board to come up with a program to assist those that have been banned from the Gathering Place. He admitted that this would take additional funding, and had no other ideas for a safe place during the day for the mentally ill banned from the Gathering Place.

Another fragile population that Health Care for the Homeless decided needed additional services was women. This year they are completing renovations on a women’s drop in center and residential facility. There is overnight space for 17 mentally ill women and 8 chemically-addicted women. The drop in center features laundry, lockers, and a lounge. The program began in collaboration with the YWCA’s New Day program, and featured transportation in the morning from the women’s overflow shelter.

The Women’s Center is scheduled to be opened until late afternoon, as well as on the weekend once renovation of the facility is complete. Most homeless women interviewed were satisfied with the facility, and were looking forward to its expansion. Some of the women interviewed wanted to see better services to assist them in moving into more stable housing.

McKinney characterized the Women’s center as, “a place that they could call their own. A place that they would feel comfortable. A place that they could feel safe and engaged and empowered.”

Barbara Danforth, Director of the YWCA, described the Women’s Center as an excellent model for a comprehensive service plan in one location to serve women. The Women’s Center is secure and has all the services to move homeless women to housing. She characterized it as a program that the YWCA developed in cooperation with CHCH. She said, ”We were not invited to participate in the program (at the time of the 1996 grant from HUD). We were not involved in the planning process.” She characterized the relationship with CHCH as one with “significant challenges” because of different philosophies.

McKinney said that the YWCA, “unilaterally chose not to be part of the Women’s Center.” He speculated that they had had a wonderful relationship at the beginning and that there had been a change at the YWCA which led to some confusion about the relationship. McKinney refused to elaborate, saying, “I don’t want to argue this in the Grapevine.”

A number of service providers mentioned in interviews that a big problem with CHCH was that they do not always stand by promises made in collaborative efforts. McKinney countered that he has a wonderful relationship with over 40 social service organizations (including the Coalition for the Homeless). He cited as an example his collaboration with the new PASS program of the Salvation Army. PASS is a shelter for chronically homeless men which attempts to move them into a stable setting.

CHCH does provide a clinic staffed by a nurse to PASS on a weekly basis, but originally had a number of beds reserved for CHCH’s chemically dependent patients. This relationship no longer exists. According to both McKinney and Salvation Army spokesperson Phil Mason, CHCH was originally suppose to receive funds for their collaborative efforts. Because CHCH receives funds from another HUD grant for the service, they cannot be paid twice for the same service from the federal government.

McKinney said, “I am fairly proud of our collaborative effort. We collaborate in (PASS) even though we were expecting funding and it ended up that we did not get one penny.”

In the past, CHCH has had some difficulty with HUD and questions regarding matching grants. McKinney said that issue is still ongoing, but was confident that the issue would not hinder the organizations continued viability. “If we were in trouble with HUD there is no way in hell that they would have given us another NOFA,” he said. No one from HUD could comment on Health Care for the Homeless.

Last year, CHCH conducted a comprehensive survey of their services in conjunction with the Federation for Community Planning. The Board of Trustees of CHCH decided to keep the survey confidential. Both the Coalition for the Homeless and the Office of Homeless Services wrote to CHCH requesting a copy of the survey to no avail. Ruth O’Leary, Director of the Office of Homeless Services, said in her letter, “While not specifically stating that the survey results would be shared formally with the community, the introduction and format implied that there would be feedback.”

McKinney said, “The decision was that (the survey) was an internal document to give us information as to where we could improve the agency… It was not something that was geared toward…the broader homeless community… I don’t have much more to say about it.”

The community survey might have provided a clearer glimpse into the services that Health Care for the Homeless offers and its position in the community. Based on a limited survey of homeless people, most are satisfied with the basic level of services which are offered, but are hopeful for an expansion of services.

Providers are split about CHCH, and there is a fair amount of concern over the administration of this nearly $1.2 million agency. This is only based on a brief survey of providers that have had contact with CHCH. The varied opinion of two similar homeless social service agencies demonstrates the difficulty in summarizing the services offered by CHCH. One provider who wished to remain anonymous said , “We love the service, and I have no complaints.” Another provider said, “The only complaint that I have is that we never know what we are going to get…There is no consistency.”

Copyright for the Homeless Grapevine and NEOCH, Issue 21, Cleveland Ohio June 1996