Missing Link Final Version

We were approached by Saint Luke’s Hospital on the Country Club Plaza in Kansas City in the fall

of 2009 to develop a program to address soaring healthcare costs associated with homeless patients.

We had been recommended as a partner by the homeless population in the area, who we had been providing meal service across the street from the hospital for years.

This undertaking fit very well with our organizational mission statement and soon developed into the partnership that turned into the foundation of our Be the Change Program

With Saint Luke’s, we identified transportation as the largest single issue related to the disconnect between their ER and the Kansas City Homeless Services Infrastructure, as the nearest overnight shelter to their ER was over 5 miles away.

Using Transportation as a primary service put us in a perfect position to advocate for clients and ensure a seamless transition of services between the steps toward recovery.

In this way, we were able to increase the collective impact of Kansas City’s Homeless Services Infrastructure to the benefit of all involved

This presentation will examine the creation, execution and evolution of our service model, and highlight the areas in which this approach and the programs it created differ from more conventional ones.

We will frequently site an academic paper that resulted from an extensive ethnographic study of our program in the summer of 2012 by Dr. James Wasserman and a team of researchers from the Kansas City University of Medicine and Biosciences and his team, which we feel effectively captures what we

do and why it works.

The World Health Organization has compared the relative impact of different illnesses across the world. According to this data mental disorders rank as the biggest health problem in North American ahead of both cardiovascular disease and cancer.

Navigation through the systems

Increase Access to treatment

Essential Qualities for Positive Therapeutic outcomes

1. Factors related to what the client brings to the situation ( about 40% )

2. The therapeutic relationship about 30%

3. Expectancy and Hope about 15%

4. An Explanatory system that guides the healing practices about 15%

This means that 60% of what accounts for whether or not a person responds to treatment hinges on the people delivering the treatment. If they develop a positive, warm, supportive and empathic relationship, support the development of hope that progress can be make, have a clear rationale for what they are doing that outlines a therapeutic map of recovery and empower the client to help themselves, there is likely to be improvement.” Bloom 2009

Service Model Supplement:

Key Partnerships: Community Partners and Funding Agencies

Kato House Emergency Intervention Center

Be the Change Program:

From Creation to Sustainability

Integrated Care: From Silos to Collaborations

None of what we do would be possible without the benefits of a few key partnerships:

Saint Luke’s Hospital founded, initiated program development, provided initial funding and reserves respite beds for shared clients.

North Kansas City Hospital has provided sustaining funds and reserves respite beds for shared clients.

The Healthcare Foundation of Greater Kansas City has studied our service model and provided vital grant funding.

QuikTrip Corporation has signed on as a corporate sponsors.

Gettlove provides us continued support.

Service Model Supplement:

Kato House Emergency Intervention Center

Since opening the Kato House two short years ago, it has provided over 4,000 nights of shelter to 58 individuals, including members of every major homeless demographic group.

This aspect of our services has become as important to our success as anything else, as it allows us total access to our clients for follow-up and guarantees a safe option for housing in between placements.

Our current organizational structure and size, along with the rationale of our service model makes brokering placements preferable whenever possible, which explains the disparity between direct and brokerage bed nights seen on the next slide.

The fact that these placements are so uncommon makes them all the more valuable, as each placement represents an instance where the client had absolutely no other option for shelter, but the seamless transition of services was able to be maintained.

As our statistical overview indicates, we have come a long way since going out on our first call in February of 2010.

In the interim we feel that we have created a program that is dynamic and effective. At this point we look to the future with the aim of creating a sustainable funding stream and an approach to service delivery that can be duplicated and expanding without losing effectiveness.

The most immediately obvious and easily measurable aspect of our service is the savings realized by our partner hospitals when we begin working with their patients.

This can be found in the reduction of volume and frequency of non-emergent hospital visits by Homeless individuals (especially those targeted as ‘frequent fliers’)

Illustrating these savings have enabled us to enter formal partnerships with two major hospitals in the area, and begin serious negotiations with 4 others. This model will allow us to continue operations as we have thus far while benefiting our customer base with an exchange rate of roughly $5 saved for every $1 invested in our program.

Even with all of the partnerships and arrangements we have been able to procure over the years, it is still a fairly common occurrence for a client to have a gap of a few days to a few weeks in between placements.

In the first days of our program we would fill these interim times with hotel stays. This strategy was reasonably effective, but had the obvious drawbacks of expense and lacked continuity of care.

In the beginning of 2011, Artists Helping the Homeless moved into an office building in mid-town Kansas City that also serves as an Emergency Intervention Center.

This arrangement gives us greater flexibility and oversight with client placements, and improves client's access to services.

Service Model Step 4 : Placement

Service Model Step 5 :

Continued Support

Service Model: Conclusions

Wasserman Report

Service Model Step 6 :

Secondary/Alternative Placement

Service Model: Conclusions

Service Model Step 6 :

Secondary/Alternative Placement (Cont’d)

Service Model: Conclusions

Service Model Supplement:

Key Partnerships: Other Service Providers

In many instances, some by design and some out of necessity, secondary placements are needed.

For example, when an individual is discharged from treatment, they are in no way fully reintegrated, and without additional support will likely find themselves back in the environment where their habits dominate, making relapse infinitely more likely.

Many times relapse or involuntary discharge may end a placement prematurely. We continue to work with our friends when this happens, however, because relapse is a part of recovery, and relapse and hospital recidivism are intimately linked.

The current strengths of AHH center on its ability to fill gaps in the network of service providers. This is well recognized, particularly where transportation has been a glaring need for some time. But it is important also to recognize that the ability of AHH to fill gaps in the institutionalized system of service provision is a direct product of its fundamentally different way of thinking about its own organization and goals. That is, without an overabundance of preconceived notions about the kinds of service it ought to provide or criteria for clients with whom it will work, AHH is able to remain fluid enough to “seep” into those gaps. Formalizing its practices in the wrong way may impact its ability to be organically responsive in that way.

Service Model Step 3 :

Build Trust/Make a Plan cont’d

At this point we work to find a placement with an appropriate service provider. Depending on the circumstance this could mean a detox bed or a spot inpatient treatment, enrollment in a transitional living program, placement in a nursing home or assistance with job searches or education.

Successful placements rely on our relationships with a network of varied service providers. We select from this network what we feel will be the best fit depending on placement availability and eligibility requirements of a given program, then work with the client to insure all necessary paperwork and documentation is in order before the scheduled intake.

In this way we navigate the service hierarchy with our clients as equals rather than providing them with a referral and set of instructions to complete on their own.

It was common to hear from AHH clients that, “The difference between what [Woo] does and the others is that he’s out here with us. He’s not sitting in some office somewhere.” (Wasserman, 2013)

After relevant placement has been found, we stay in communication with our friends to provide additional support or advocacy. This is a large divergence from many other service providers, but is vital to “seamless transition of services”

Full recovery and reintegration almost never takes hold after only one “successful placement.”

This role blends outreach and social work in a very intensive manner in the still dominant continuum of care model individuals are ideally routed from emergency shelter, to detox, to in-patient rehabilitation, and then to transitional housing. But these various services are often run in relative isolation, or at least poorly coordinated. This produces gaps in the continuum that individuals often fall through. AHH acts as a liaison through the entire process, sealing the gaps. As one of the research team members observed, “He’s like the hemoglobin in the blood, making sure oxygen gets where it needs to go. Without it, the whole (organ) system would just die.” (Wasserman, 2013)

We do not stop working with clients as long as they are genuinely committed to recovery and willing to make a personal effort.

This philosophy does contribute to an ever-expanding workload for our program, but we plan to increase our capacity for service delivery in step with this increased demand.

In the operation of this program, it has become very evident that the time in between more significant placements is vital, we work closely with a number of organizations to make temporary placements to “hold onto” clients while other, more lasting arrangements are made.

We have arrangements and understanding with several area service providers that help us fill these gaps, however there are always those who truly don’t have any options. Sheltering these clients and maintaining the progress that has been made is be the primary function of the Kato House“Emergency Intervention” Center.

Additionally, AHH clearly works well with the clients it serves.

Not only does it develop a more longitudinal and trust-based relationship with clients, but also this appears to bolster its efficacy and efficiency, where, for example, clients are less likely to fall through gaps in the continuum of care because AHH provides consistency throughout those steps. AHH also provides resources and services to those systematically excluded from other service agencies. This is both because they organically respond to need rather than prefabricating ideas about target populations and because they retain a very positive reputation among the most alienated groups of homeless individuals.

Kato House Emergency Intervention Center

Looking forward we plan to continue to grow our organizational capacity and expand service offerings, without losing sight of the things that make us unique.

We feel that these qualities have-both by accident and by design-helped us to create something that works and reduces the recidivism of homeless for the hospital.

Probably the biggest testament to the impact of our service can be found in the emergency room admissions for the homeless patients is down 88% at Saint Luke's, our first partner hospital since we began our program in 2010.

We are excited to continue to serve as the missing link for our community's homeless, and hope that the ideas and strategies discussed in this presentation will be applicable and beneficial to other organizations in the future.

In the last three 3 years we have been able to provide a significant volume of services to a large population of clients from every demographic sector of the homeless community.

The key attributes of our organization that have facilitated this development are:

1. Working from the bottom up, alongside our clients.

2. Increasing the Collective Impact of our partners by filling gaps in services with frictionless collaboration.

3.Approaching case management from an artistic frame of mind, but operating within preexisting institutional structures.

4. Illuminating the multifaceted benefit of the work we do to our community, our partners and our clients.

5. Creating a funding stream outside of conventional channels that eliminates competition with our partners.

Other Notable Statistics

Detox

Intervention Strategies are formulated with client goals, preferences and past experience in mind. In this way, we operate as a partner in recovery rather than an authoritative body, and develop strategies that are unique to each client. It is in this stage that the artistic mentality of our service delivery is manifest:

Focus on quid pro quo arrangements between clients and providers (market logic) and on efficiency and measurable outcomes (industrial logic) create systematic gaps in the scope of services. (Wasserman and Clair, 2013).

In contrast, artistic logic utilize intuitive forms of thinking that engage empirical phenomenon in a creative process—whether those are a thought or feeling one wishes to convey on canvas or a plan one wishes to cultivate in collaboration with a homeless client. (Wasserman, 2013)

Kato House Emergency Intervention Center

We have arranged for priority placement of our clients with a number of area service providers.

Overnight Shelters:

Kansas City Rescue Mission - ReStart - City Union Mission

Social Detox Facilities:

Salvation Army MOSOS - KCCC

Inpatient Treatment Facilities

Gateway - ReDiscover - Imani House

We also have staff sharing agreements with ReDiscover and Kids TLC to reduce overhead costs.

Our organization has also benefited significantly from the talents and expertise of a wide range of college interns from the University of Missouri Kansas City, Park University, Avila College, and Mid America Nazarene University Schools of Nursing and Social Work. These students have helped us to staff our program and lent their field specific expertise.

Service Model Step 7 :

Continued Support and Communication

Education

Leverage existing funding and resources by filling Gap services

17,473 Total trips to provide services

13,148 Total Rides in which clients were transported

2,373 Total Clients assisted

4,927 Total Bed Nights provided by Artists Helping the Homeless

30,124 Total Bed Nights provided through placements with partner organizations

1,587 Total Overnight Placements

442 Total Social Detox Placements

147 Total Inpatient Treatment Placements

218 Total Transitional Living Placements

In the future we plan to expand the service options available through the Kato House to offer onsite individual and group counseling as well as healthcare resources.

We will also have a greatly increased capacity to house people, with a thirty clients at a given time.

We will remain with our current approach of deferring services to outside providers whenever possible and appropriate, this expansion will just make the time spent between placements more productive and beneficial for clients.

Service Model Overview:

Why it Works: Collaboration Cont’d

A brief point of clarification: the number of direct nights of shelter is

Notably higher than the number of nights provided at the Kato House

quoted on the last slide because there have been numerous instances

when the best option was to place a client in a hotel before and since the Kato House opened.

Steps IV-VI can repeat themselves any number of times in a given situation, but we believe in continued collaboration for as long as is necessary if all parties involved are committed to improvement.

Especially when dealing with chronically homeless populations, steadfast advocacy without enabling is absolutely essential.

Anytime off the street provides hospital emergency department short term savings. Attaining the ultimate goal of getting off the street provides long term savings.

Reduce Waiting Time  Reduce No-Shows 

Increase Admissions  Increase Continuation

Client-centered approach  Meets the client where they are at  Self-determination  Self-autonomy  Non-judgmental

Respect individual differences 

Tolerance for disagreement and ambivalence 

Patience with gradual changes  Caring and interest in client  Not the expert, but a partner 

Willing to negotiate with the client  Open to ideas from client  Supports what the client wants to do

Provides a framework for coordinating Multiple systems, services and supports that are person centered and designed to readily adjust to meet the needs of the individual’s needs and chosen path to recovery.

We demonstrate the value of our service to the community at large, and now receive referrals from local governments and police departments, businesses and private citizens.

This provides our city with a humane, effective, efficient means of accessing the Homeless Services System and eliminates situations that may otherwise devolve into more stereotypical interactions between Homeless people and society at large.

Hospital

Treatment

The Missing Link

Care

Coordination

Counseling

Service Model Step 3 :

Build Trust/Make a Plan

Estimated Community Savings

If the client is receptive, and we have relevant contacts/partnerships that we can utilize to the person’s benefit, we create a plan of action with the client.

Service agencies typically utilize a programmatic model that often prefabricates service protocols, rather than developing them in response to the individuals that present to their institutions. (Wasserman, 2013)

In many cases we build trust slowly over the course of multiple rides before a client opens up and asks for assistance.

We find this approach to be highly effective with our more challenging clients, many of whom are distrustful of service providers and community agencies because of past experiences.

“… many of the people we spoke with, both clients of AHH and other service agency workers, noted that the relationship that AHH has with those they serve is exceptionally good. Some individuals who felt alienated from every other service in the city nonetheless reached out to AHH.” (Wasserman, 2013)

Service Model Step 2 :

Transportation

This chart attempts to quantify the savings our program has generated in healthcare costs averted via services provided and placements we arranged.

Financial statements from Saint Luke’s Hospital confirm these estimates, and actually make them appear modest.

Artists Helping the Homeless Service Model

and the Importance of

Seamless Transition of Services

Service Model Overview:

Why it works

Kato House Emergency Intervention Center

Kato House

Kato House Emergency Intervention Center

A comprehensive menu of services and supports that can be combined and readily adjusted to meet the individual’s needs and chosen pathway to recovery.

Much of what works about our program developed organically over time as we partnered with our clients to come up with solutions.

We realized that these solutions were beneficial for the clients themselves, other service providers and the community as a whole.

There are a few important factors to take into consideration when considering our divergence from more conventional service models:

Perspective

Organizational Flexibility

Collaboration over Duplication or Competition

JT is a 24 year youth from Kansas City's urban core and a long time client of AHH. We helped him to go through treatment and enroll in Jobcorps in early 2011.

JT contacted us in mid February and said that he had been slipping back into substance use and needed treatment. We arranged social detox and inpatient treatment for him a week later.

Unfortunately, JT was discharged from treatment after less than a week in the placement due to an altercation with another client.

Rather than returning to the streets, JT called us and we were able to work together to make arrangements at another treatment facility.

JT stayed at us between placements. In that time we were able to make sure he had the necessary identification and paperwork in order for the second facility.

JT is in treatment as we speak because he knew that we were a viable resource even though we hadn't spoken in over a year, and because he knew we would continue to try as long as he did.

We would now like to take a chance to share some anecdotal evidence from the last few weeks to further illustrate the necessity of this type of placement and give some examples of the unique nature of client placement, needs and interventions.

Service Model in Action:

Statistical Analysis

Service Model Step 2 :

Transportation cont’d

Service Model Overview:

Why it Works: Collaboration

Artists Helping The Homeless

Service Model Rationalization

Transportation

The following slides will discuss the statistical findings for Artists Helping the Homeless after 3 years of operating the

“Be the Change” Program. Conclusion of the efficacy of this model can be drawn from these findings.

Job

Training

Rider Referrals

Artists Helping the Homeless

Service Model

Rider Destinations

Rider Category Total

Transitional

Housing

Permanent

Housing

Total Rides by Month

With receptive clients, the time in the van is used to become familiar with the individual’s situation and goals

This point another key variation between the AHH approach and the prevailing model of service delivery.

AHH is organized around a pedagogy that permits creative, dynamic, and individual collaboration with clients and does not presuppose appropriate goals or processes for working with them. (Wasserman, 2013)

Follow-Up Rides

Service Model Step 2 :

Transportation

Our program was conceptualized with the ambition of creating a service that would meet clients in their surroundings and provide supplemental support to the significant service offerings already in place in Kansas City.

This was undertaken to address soaring health care costs associated with homeless presentations in Kansas City Emergency Rooms

In the three years since our program started we have:

Reduced Emergency Room Presentations by Homeless individuals by 88% at one area hospital

Saved our community over $5 for every $1 invested in our program

Saved area hospitals an estimated $4,375,000

Service Model Step 1: Referral

In the beginning the only service we offered was transportation. In light of this we had to rely entirely on the existing service infrastructure to meet client needs.

As we became familiar with available services we labored to match clients with services in a way that increased the success rates for everyone involved and even take on some of the intake responsibilities for our partners.

The brand of wrap-around case management that we practice also increased successful discharge rates for partner organizations.

Over time we also became a referral option for these organizations.

Because our funding stream and outcome measures operate largely outside of the highly competitive grant funding pool, we were able to create frictionless partnerships with service providers all over Kansas City.

This significantly reduces duplication of services, as we are not fighting to take credit for the same outcomes, and increases the Collective Impact of the Homeless Services in the region.

Service Model Step 1:

Referral cont’d

This chart highlights a number of the organizations we work with most closely. Please note the variety of hospitals, service providers and other organizations present here.

We have established relationships with hospitals, schools, businesses, government agencies and other service providers throughout metropolitan Kansas City.

When one of these organizations encounters a homeless individual with a valid need for transportation they are referred to us.

At this point the client, or someone advocating for the individual will call us to request services.

An initial ride and/or consultation is then arranged when appropriate.

After a referral is made, we provide the individual with transportation to meet an immediate need. This transportation is provided without any agenda or expectation of our clients.

Everyone that receives services fills out a brief intake form with demographic data, but if there is no client interest, no further engagement takes place at this time

While transportation and physical barriers to accessing services are important, equally important is the creation of new forms of engagement for those who are homeless, i.e. new protocols for social work delivery, that correct the rigidity of modern institutionalized models (Wasserman and Clair 2010, 2013).

With the possible exception of our first few months in operation, we have consistently found that the only limiting factor on the number of rides we provide is our capacity. We have been continually amazed by Kansas City’s homeless population’s need for transportation.

This chart illustrates the nature of services we provide as a ratio. Notice that “Standard Rides” make up only 13% of all services. These are the rides in which a client was picked up for the first time. As you can see, a great majority of services are provided to returning clients.

This graphic tracks the locations we have taken riders.

The variety of locations is another example of the diversity of our network.

This chart highlights the demographic profile of our client population. You can see that we have significant interactions with every sector of the homeless community.

Client Center Approach

Hospital referrals make up nearly 1/3 of all rides we provide, and account for over 1/2 of the Chronic Homeless clients we served

This population is especially important for us, as they have an established record of hospital presentation, and may stand to benefit most from coupling with more appropriate services to meet their basic needs.

Kato House Emergency Intervention Center

Service Model Overview:

Why it Works: Perspective

TN is an electrician by trade and a long time alcoholic. In recent months his alcoholism has cost him his family and his home. Last week he decided for the first time that he was ready for inpatient treatment for his substance abuse issues.

We made arrangements for TN to get into treatment, and brought him to our facility to stay the night before his intake date to insure that he would be on time to his early morning appointment.

Several hours after arriving at our building TN began suffering from fairly severe withdrawal symptoms.

We were able to work with one of our partner hospitals to get him withdrawal medications and stabilize his condition before intake.

In spite of all of this, the treatment facility could not let him in without Detoxing first.

We were able to arrange an immediate transfer to a Social Detox facility and extend his stay there until his next bed date came around at the treatment facility.

The second time he entered treatment without difficulty.

This sequence of events would surely have gone very different were it not for TN’s stay at our facility and our comprehensive case management.

Service Model Overview:

Why it Works: Organizational Flexibility

Kato House Emergency Intervention Center

When we began this project, we brought a very unconventional perspective and approach to our mission.

Our Executive Director was a successful businessman and artist operating a retail store for 30 years. Studied Business and Psychology/Counseling in college.

He brought with him the mentality of an artist and an effective business negotiator.

We did not come in with any formal training in social work or conventional orientation to the homeless services system.

Enlisted advice and support of the staff and management of hospitals and homeless agencies.

As a result we learned to navigate the system right alongside our clients, and retain that bottom-up over top-down mentality to this day.

Our Start-up funding was supplied with very few strings attached, which allowed us to operate as we saw fit.

We were presented with the mandate to use transportation to reduce non-emergent hospital presentations by homeless clients.

This freed us from the limitations of a pre-defined client base or catchment area and allowed us to simply help those who needed it.

The hospitals recognized the same homeless individual would present themselves in multiple hospitals, sometimes daily.

We were also able to intervene in area’s that other service providers could not.

It was not uncommon in the first days of our program for us to put clients up in hotel rooms while they waited for bed dates, this strategy was fairly unheard of at the time, but proved much more effective than making them wait on the streets.

In time we were able to illustrate our efficacy related to our initial mission, and in doing so continue to receive funding without many stipulations.

We realized the importance of this latitude and work very hard to keep it in place.

IW is a youth who has been staying at our center since the fall of 2012.

In the time he since he began staying with us, IW was able to take care of a number of legal issues he had pending, begin classes in a nearby community college and find employment.

After finding work, IW had made arrangements to move out in late February, but was involved in a serious car accident days after leaving.

We were able to allow him to return and provide transportation services enabling him to stay on track with his employment and education. This support should allow him to be self sufficient in a few months, and prevent him from going back to square one.

The Acute Care model of addiction treatment is characterized by its crisis-linked point of intervention, brief duration, singular focus on symptom suppression ( achievement to abstinence), professionally dominated decision-making process, short service relationship, and expectation of full and permanent problem resolution following “Graduation” White 2008

Shifting from a crisis-oriented,

professionally-directed, acute-care

approach with its emphasis on

isolated treatment episodes....

To a person-directed, recovery

management approach that

provides long-term supports and

recognizes the many pathways to

health and wellness.