Part IV: The good, the bad and the ugly: tracking brain injuries, health care for the homeless

Street Roots is running an in-depth investigative series on Brain injuries and homelessness. Read “Part I: All in their heads, Part II: Why Diagnosing traumatic brain injuries on the streets matters,” and “Part III: Brain injuries push victims into homelessness”

By Stacy Brownhill, Staff writer

Complaining about health care and health insurance is a national pastime in the US, but when you’re homeless and mobile, without insurance or a regular doctor, health care is truly an uphill battle. Tracking and sharing the health history of a homeless person across multiple systems is fundamental in providing better care, reducing costs, and creating a more efficient and successful system of safety nets. But it’s rare.

The good

Every night when the clock strikes 12 in San Francisco, records from over a dozen incompatible safety-net databases – including data from shelters, ambulances, mental health services, hospitals and sobering centers – are dumped into one central digital warehouse called the Coordinated Case Management System (CCMS). Once there, the data is collated and duplicates are deleted for an end result of around 270,000 individual profiles of vulnerable people, about 50,000 identified as being homeless, or formerly homeless.

The noble success of CCMS is that it provides a benefit to overburdened agencies without requiring them to change their systems or do any extra work. The next time a homeless person walks into any safety-net agency in San Francisco, a social worker or physician can simply click a link to CCMS and see a client’s complete health and social service history.

And it’s inexpensive. Three committed employees of the San Francisco Department of Public Health created CCMS, without extra funding, using the software Oracle.

Boston is another innovative hub for health care for the homeless systems. From 1993-1995, Boston merged records of 75 different clinics and soup kitchens into one database using Centricity software. “It has helped us begin to understand homeless people’s patterns of behaviors,” says O’Connell with Boston’s Health Care for the Homeless Program. “If I’m seeing someone at the Pine Street Inn shelter on a Friday night and they had been seen at a soup kitchen the day before, I see that on their record.”

The Homeless Youth Service Continuum in Portland is another example of shared systems, albeit a micro-approach that only targets homeless youth ages 13-21. Outside In, New Avenues for Youth and Janus Youth Programs double-enter records into a common database that is available to several youth homeless providers.

Double-entering gets challenging when organizations are interested in tracking different things, often motivated by grant reporting, or when agencies have different definitions of data points, says John Duke, health clinic director at Outside In.

MiVIA is an online health database launched in California in 2003 to provide electronic health records for migrant workers, whose transient lifestyle means discontinuity in health care. The mission of MiVIA revolves around saving time and money by avoiding duplicate tests. Web-based records like MiVIA have enormous potential among the homeless population.

The bad

“We’re trying to make sure all clinics are connected but it depends on which clinic you go to,” says Chase.

“Right now, (healthcare for the homeless) isn’t really tracked that easily,” says Duke, who must request records from other clinics once patients tell him they’ve been to those clinics.

Portland’s closest thing to a homeless tracking system is the Homeless National Information Systems (HMIS), a U.S. Department of Housing and Urban Development (HUD) sponsored program. HMIS is limited, however, because only data from HUD-funded agencies is collected. And clinical information is excluded.

“HMIS could potentially work like CCMS if it collected information from non-HUD safety-net agencies and included clinical records,” says Maria X. Martinez, who headed the creation of CCMS and works in the Director’s Office of the Department of Public Health in San Francisco.

And the ugly

“There are not always incentives to create a common database for homeless health care,” says Duke. “Hospitals are competitive.”

“Even though it is completely legal to share records through electronic databases, physicians from different hospitals get nervous about increased liability,” says Martinez, a former specialist in health information privacy laws. “Picking up the phone to discuss a case is one thing, but codifying information is unnerving for institutions.”

With the exception of substance abuse records, however, records from social workers, primary care physicians, psychiatrists, case managers and shelters are all fair game to share among providers of care, says Martinez.

Martinez will be the first to admit that even CCMS has major flaws. Despite being an enormous wealth of information about a homeless client, CCMS usually comes in second to an agency’s own database. Social workers might make time to look at both sets of records, but physicians who are pressed for time may not, says Martinez.

Then, there’s the question of what to do after data is shared. “So-what-now-what?” asks Martinez. “What’s the next step? We’ve seen that sharing information alone doesn’t change practice. (Sharing information) is a whole new way of delivering care because you don’t just have your toolkit; you have many agencies’ toolkits. So we’ve got to change our protocols and our whole way of thinking.”