By Amanda Waldroupe, staff Writer
“Frankly, they shock me.”
Those were the words City Commissioner Nick Fish used to describe the results of the Vulnerability Index survey when it was given to 646 homeless individuals over the course of three mornings in October 2008.
The survey revealed that 302 people, nearly half of all surveyed, were considered “medically vulnerable” because they had diseases increasing their likelihood of dying while homeless, such as heart disease, end-stage renal disease, and cancer. More than a third of those surveyed, 231 individuals, were considered “tri-morbid,” because they had co-occurring physical and mental illnesses as well as a substance abuse issues.
“We had a good sense that people who were homeless and living on the streets were more likely to be more ill. The proportion was higher than we had expected,” says Ryan Deibert, a homeless program coordinator at the Portland Housing Bureau.
Fish vowed change.
“It did have an important impact,” says Nic Granum, the program manager of Central City Concern’s Recuperative Care Program. “It made the City think about spending its money differently.”
Within months, two people on the Index’s list of medically vulnerable were rapidly housed by Central City Concern’s Recuperative Care Program, which provides medical care in a transitional housing setting. Cascade AIDS Project found housing for a handful of people with HIV/AIDS, and homeless veterans received housing vouchers from the V.A.
Portland’s two warming centers — one for single men and women, and one for families — begin that fall. Part of the urgency to create 150 additional places for people to sleep during the winter months came from the results of the Vulnerability Index survey. 60 shelter beds that previously existed were prioritized for medically vulnerable people.
Funding also increased for programs serving the most medically vulnerable homeless people. The Recuperative Care Program has received an additional $50,000 in funding in 2009 and 2010, increasing the program’s capacity. The funding is used to provide 10 individuals with stable housing and medical support and 40 individuals with primary care, ensuring that 75 percent of those individuals will resolve their medical issues and 100 percent will have stable housing.
The Vulnerability Index was also used as a tool or piece of the housing bureau’s argument for funding.
“We finished the Vulnerability Index not too far ahead of the next year’s budget process,” Deibert says.
And a recession.
All city bureaus faced at least a 5 percent cut in their budgets. The Portland Housing Bureau’s budget was increased by 30 percent. “At least part of the momentum that helped expand that budget came from this clear demonstration just how vulnerable people experiencing homelessness were,” Deibert says.
The Vulnerability Index has also changed the way people talk about homelessness.
Once perceived as a public safety issue and how homeless people affect society, policy makers now consider the problem of homelessness from an individual homeless person’s perspective. Rarely does Fish speak about homelessness without referring to homeless people as our “brothers and sisters” and the moral obligation government has to house them.
“We talk about Portland’s most vulnerable citizens,” Deibert says.
The Vulnerability Index has had definitive effects, both short and long term, on Portland’s efforts to end homelessness. Despite its effectiveness, the Portland Housing Bureau is not continuing to administer it. Last year, housing bureau members, advocates and service providers volunteered their time to conduct the survey over the course of three mornings starting at 5 a.m.
“It’s a difficult tool to operationalize on an ongoing basis,” Deibert says.
Regardless of the city’s efforts to date, people will inevitably continue to become ill, even die, while living homeless in Portland. To not continue making a link between the health effects being homeless and housing placement, sources say, amounts to a missed opportunity.
“I think we need to gather as much info as we can about people on the streets,” says Rachel Solotaroff, the medical director of Central City Concern’s Old Town Clinic. But, she adds, it is difficult to determine who gathers the information, when, how, and what it will be used for.
The Housing Bureau is currently looking for a similar tool to replace the Vulnerability Index. Sally Erickson, the Bureau’s homeless program manager, is examining whether or not to adopt a program similar to the one developed by the Downtown Emergency Service Center, a service agency in Seattle.
It is like the Vulnerability Index in that it surveys homeless people about their physical health. But it goes a step further in gaining knowledge about someone’s mental or behavioral health, and analyzes the ways in which physical and mental health affect one another and make a person more or less vulnerable.
The tool shows, for example, that a 70-year old woman suffering from schizophrenia unable to regularly shower is more vulnerable—and should be housed more rapidly than — a 22-year old struggling with depression.
“We felt (it) better captured elements of vulnerability beyond physical health,” Erickson says.
Erickson says the bureau is currently thinking of ways such a tool could be used in Portland and hopes to have a plan flushed out sometime in the late spring.
What there are no plans for, however, collecting information on the number of homeless people who die each year while homeless.
Seattle and King County monitor the number of homeless people dying each year. Janna Wilson, project director for Health Care for the Homeless Network, a consortium providing health care for homeless individuals, says the program was started in 2004 due to pressure from local homeless advocates.
Since the program began, the Medical Examiner’s office has counted 374 homeless individuals who have died between 2004 and 2007, according the most recent report.
“This use of Medical Examiner data to try to get a handle on homeless deaths is very, very limited because you’re only getting limited information on that subset of people who die under certain circumstances,” Wilson says. “Most homeless people are dying from chronic health conditions. They’re dying in hospitals.”
The King County City Council allocated $20,000 to King County’s Medical Examiner’s office to coordinate with Health Care for the Homeless. The Medical Examiner did not have a method for counting homeless people. “They could make an assumption,” Wilson says. “It wasn’t a piece of information that was regularly collected.”
The information on deaths also charts the average age of those who died: 48 for men, 46 for women.
The money was used to buy new statistical software that allowed the medical examiner to add the field “likely homeless.” The course of an examiner’s investigation into the cause and manner of a person’s death, and their identity, leads them to the person’s last known address. If that address is for a shelter or motel, or if the person is using motel vouchers, staying in vehicles, abandoned buildings, parks, sobering centers, or tent cities, he or she is categorized as “likely homeless.”
Wilson says that it is still ultimately a judgment call by using that method.
“I know that the advocates find the information useful,” Wilson says. “Does it tell us new information every year? Does it drive us to change our programming? Not in a substantial way.”
To the surprise of Wilson at the time, it resulted in increased funding for homeless services in King County. In 2005, State Rep. Mark Miloschia, who represents southwest King County, co-sponsored a bill that added $25 million to Washington’s Housing Trust Fund in an effort to expand the amount of affordable housing throughout the state.
Dr. Karen Gunson, Oregon’s medical examiner, says she has no intent to begin keeping track of the number of homeless people dying each year. She cites the lack of financial resources, a small staff, and the lack of appropriate statistical computer software as why.
“If I had the money, I might do that. I have other pressing needs,” Gunson says, mentioning providing forensic pathology services to other counties.
Gunson also says that the majority of people arriving at the Medical Examiner’s office are not homeless. She guesses that one or two individuals a month are homeless. The medical examiner’s office had more than 60 cases since the beginning of the year, with one person coming from a homeless camp.
Gunson says she has not been approached by anyone at the Housing Bureau or any homeless advocates to start a program similar to King County’s. Neither Deibert nor Daniel Ledezma, Fish’s housing policy advisor, would comment on whether there would be value to monitoring the number of homeless people dying each year in the Portland area.
Developing ways of counting the number of homeless that die each year was a discussion topic during the Coalition for a Livable Future’s annual summit on regional livability this past May. Two points made during that discussion were using such information to lobby for additional funding for homeless services. A second regarded improving coordination and communication between homeless service providers and health care networks.
The Coordinating Committee to End Homelessness, a stakeholder group in charge of implementing the 10-Year Plan to End Homelessness, met on Feb. 17 to assess the “state of the 10-Year Plan,” at the half way mark. Between discussion of how the 10-Year Plan has worked, hasn’t worked, and improvements needing to be made, there remained an elephant in the room: the lack of a dedicated source of revenue for affordable housing development and related services in the Portland area.
Dr. Wayne Cells, Outside In’s medical director, thinks a stronger link needs to exist between homeless service agencies and Portland’s health care system.
“You can’t disconnect them,” Wilson says.
Cells says that it is difficult for homeless people to prioritize maintaining their health because they are so focused on finding adequate and safe shelter, and food. It is common, he says, to put health care off until “it reaches crisis level,” which in turn results in emergency room visits and higher costs.
Homeless people also have a more difficult time dealing with diseases that present no physical symptoms, such as high blood pressure. “They’re never going to know and they’re never going to seek care,” Cells says.
Cells says it would go a long way toward understanding people’s medical conditions and increasing the level of care they receive, even if agencies required a physical exam as a requirement to enter housing or receive services.
“I don’t know if the survey would make any difference if the money wasn’t there” to create more services and housing, says Robin Bock, the nursing supervisor at the West Side Clinic, a medical clinic for low-income people operated by Multnomah County’s Public Health Department.
Nic Granum at Central City Concern agrees with the idea of a stronger link, saying people are still being discharged from hospitals into homelessness, which only increases the severity of their illness in the long run, and drives up the costs of providing services for them.
“Having everyone on board is what’s helping those people,” Granum says.
Granum uses the example of a homeless woman he and the Recuperative Care Program is currently working with. A number of people worked with her — including medical staff, housing placement staff and other support services — for one year before she was able to receive and stay in long-term housing.
“Getting the people who are socially compromised and medically vulnerable (housed) takes a long term effort,” Granum says. “It can’t happen overnight.”