Improving Dental Care

In each issue of The Robert Wood Johnson Foundation Anthology, we present a close look at a single project representing a smaller than typical investment by the Foundation, in the hope that it will tell, in more intimate detail, the story of how the project evolved, who the players were that made it happen, and what general lessons can be derived from it. This chapter focuses on the Homeless Prenatal Program, a small nonprofit organization in San Francisco dedicated to working with pregnant women who are homeless.

It has received grants for three separate projects from the Foundation since 1992. Two came through the Local Initiative Funding Partners program, under which the Foundation offers matching grants to create partnerships with local foundations to support innovative, community-based projects helping underserved and vulnerable populations.¹ The Homeless Prenatal Program was one of a very few that were given two Local Initiative Funding Partners awards: the first for its work with homeless pregnant women and the second for its work providing services to women leaving prison. (The third Foundation-supported project was under the Opening Doors program, a collaborative effort with the Henry J. Kaiser Family Foundation that funded projects attempting to lower social and cultural barriers to health care services.)

This chapter, written by Digby Diehl, a best-selling author who has contributed chapters on a wide range of topics to previous volumes of The Robert Wood Johnson Foundation Anthology, highlights the passion and charisma of Martha Ryan, the founder and executive director of the Homeless Prenatal Program. Ryan was named a Robert Wood Johnson Community Health Leader in 2003. Diehl makes the point that viability in the nonprofit world requires both the hard work and creativity of individuals such as Ryan and financial support from funders.

He ends the chapter by raising the question of whether programs like the Homeless Prenatal Program can be replicated widely or whether they depend on unique local circumstances and charismatic leaders. It is an important question with which The Robert Wood Johnson Foundation and other foundations continue to grapple.

On any given night, between seven hundred thousand and eight hundred thousand people are homeless in the United States.1 On an annual basis, between 2.5 million and 3.5 million people in America are estimated to be homeless. Approximately half of the people in these estimates are families with children.² Families are the fastest-growing segment of the homeless population.³ Furthermore, many homeless families are headed by a female facing multiple challenges, including substance abuse, physical and mental disabilities, histories of abuse and violence.⁴

“Family homelessness is a growing national tragedy,” says Ellen Bassuk, founder and president of the National Center on Family Homelessness and associate professor of psychiatry at Harvard Medical School. “It is a new social problem, and has grown exponentially in the last twenty years. It is most serious in our urban areas. For example, it is estimated that in New York City, 75 percent of the homeless population are families.” Offering an analysis of why there has been such a rapid growth in homeless families, Bassuk explains, “There has been a dramatic increase in female-headed families, and these tend to be the poorest and most vulnerable to becoming homeless.”

A 1997 study of 436 homeless and low-income families with female heads found that the mothers in the study had an average age of twenty-seven and had two children. They were extremely impoverished in comparison with the national income norms (about half survived on less than $7,000 a year) and were socially isolated. “A staggering 92 percent of the homeless and 82 percent of the housed [low-income] mothers experienced severe physical and/or sexual assaults at some point in their lives,” according to the study. “More than 40 percent in both groups were sexually molested as children. By the age of twelve, 60 percent had been severely physically or sexually abused.”⁵

To confront this problem at the local level, an outreach and support network for homeless families, the Homeless Prenatal Program, was founded in San Francisco in 1989. Since its beginning, with one nurse practitioner named Martha Ryan personally providing prenatal care for homeless women in one shelter, the program has expanded into a $1.7 million organization of thirty employees that offers a support network of services and guidance to 1,800 homeless families throughout the city.

Ryan says that there is a long tradition of volunteerism in her family. “We lived in Japan for much of my youth, and my mother volunteered in the hospitals to care for American soldiers injured in the Vietnam War,” she said. “I remember learning to knit clothing in Catholic school so that we would have something to give to the poor. After I graduated from the University of San Francisco, I had no idea what I would do with my life, but I loved to travel, so I decided to apply for the Peace Corps. When they told me I was being sent to Ethiopia, I don’t think I could even find it on a map. After two years of teaching English in beautiful villages to those beautiful people, my life was changed forever. I came back to study nursing because I wanted to give something more substantial to Africa than English lessons. While I was back here working on my nursing degree, I discovered a whole population of homeless pregnant women who needed my help right here in San Francisco.”

Today, although the program no longer offers direct medical care, it has become a comprehensive system of supports for poor families. In addition to family counseling and referral to prenatal care, it works with clients to provide food, housing, parenting education, substance abuse assistance, and advocacy within the courts and Child Protective Services. There are no requirements and no charges for these services. They are provided to any woman who asks for or is willing to accept help from the program. The program is unusual in that it acts as a link that has been missing in the homeless support network: it is a way to penetrate the barriers between women on the streets—who are often confused, addicted, and frightened—and the programs designed to assist them, which are often cold, bureaucratic, and difficult to access. The long-term aim of the Homeless Prenatal Program is to break cycles of poverty, incarceration, and homelessness, and to help each family to build a healthy and stable life.

The Homeless Prenatal Program originated in the Hamilton Family Center in the Haight-Ashbury district, which in 1988 was San Francisco’s only city-funded family shelter for the homeless. “It was just a bunch of good-hearted people at the Hamilton Church who fixed up the basement so that anyone who was homeless could find a mattress,” recalls Marian Peña, who volunteered at the shelter with Martha Ryan in the late 1980s. “Hamilton was really bare bones. You showed up, you got a bed when you needed it. No questions asked. Martha and I were both working at the Southeast Health Center, going to school, and volunteering at the shelter. Martha saw the surprising number of pregnant women coming to the shelter and decided to do something about it on the spot.” With Peña and another colleague, Mary Kate Connor, Ryan set up a prenatal clinic in a one-hundred-square-foot closet in the Hamilton Family Center. The cramped quarters and suspicious, resistant clients made it difficult to provide continuing prenatal care under the auspices of a city program called “Health Care for the Homeless.” Because the clinic could see this highly transient population only on a part-time basis, it was hard for the volunteers to maintain contact with a woman throughout her pregnancy.

“Initially, there were three pregnant women that I began to treat at the shelter,” Ryan says. “All we had was space for an examination table and a door to close for privacy. I had a Doppler for ultrasound and a stethoscope and could perform a basic prenatal exam. But there wasn’t even a sink. More pregnant women came for services, and many of these women were not even staying at the shelter. Some of these women had previously resided at the shelter, but could no longer do so because the shelter limited stays to thirty days. Even when staying elsewhere, these women still came back to the shelter to receive prenatal care. This was also true of women who had left the shelter amid some controversy, which was not uncommon.”

“The number of homeless pregnant women came as such a surprise,” Ryan remembers. “In fact, the first time I was told that there were homeless pregnant women, I said, ‘How can that be?’ Of course, it didn’t take long to figure out that if a woman was homeless, she would be poor. If she was poor, she wouldn’t have health care, but she still would be having sex and so she would get pregnant. After that first year when we saw seventy-two pregnant women, it was clear that there were a lot more homeless pregnant women out there than I could deal with in my little closet clinic. We knew that we had to move to a larger, more neutral space.”

During that first year, Ryan also had an insight that became one of the cornerstones of the Homeless Prenatal Program. She saw that pregnancy could be a window of opportunity in a woman’s life—a turning point focused on the new responsibilities of motherhood. “Many of these women had poor self-esteem and self-destructive tendencies,” Ryan recalls, “but I never met one who did not want to have a healthy baby.” She decided that the Homeless Prenatal Program could capitalize on this opportunity—could help women break drug habits, find jobs, end abusive relationships, and become good mothers.

While working at San Francisco General Hospital and volunteering at the Hamilton Center, Ryan was simultaneously studying for her master’s degree in public health at the University of California, Berkeley. For a class in grant writing, she wrote a practice grant proposal on homeless prenatal care and sent it off to the only foundation she had ever heard of, the San Francisco Foundation. It landed on the desk of a program officer, Ruth Brousseau. “I was stunned when I got Martha’s proposal,” Brousseau says. “No one else had ever addressed the problem so directly. I set up a meeting with Martha and helped her to revise her grant proposal. She had asked for $150,000 a year for each of three years, but I knew that the San Francisco Foundation couldn’t fund her for that much; so we pared her initial proposal down to $52,000 a year for three years. I advised her to start small, prove that the program could work, and then expand.” The board approved the grant; by 1990 the clinic was serving 150 homeless pregnant women, and its resources were overtaxed. Ryan and her associates were frustrated by women being asked to leave the shelter before delivery and finding that it was increasingly difficult to maintain contact with women living transient lives.

In the spring of 1992 the Homeless Prenatal Program registered with the Internal Revenue Service to become a 501(c)(3) nonprofit organization and was preparing to move into a larger location. The program had reached a level where the San Francisco Foundation’s Brousseau encouraged it to apply for a Robert Wood Johnson Foundation grant. With the help of Brousseau and the program’s new administrative director, Julia Velson, the San Francisco Foundation nominated the program for a grant from The Robert Wood Johnson Foundation’s Local Initiative Funding Partners program. The Robert Wood Johnson Foundation was joined by three others—the James Irvine Foundation, the California Tamarack Foundation, and the Koret Foundation—to provide matching grant dollars. These local foundation partners are significant because the Local Initiative program is a national matching grant program that seeks to establish partnerships with foundations in the community in order to provide a stable local funding base.

“The Local Initiative Funding Partners program is very much about its name,” says Pauline Seitz, the program’s director. “These are local grants; they are for community-based organizations ready to take initiative by adopting a proactive approach to a local problem; and it is very much about the funding partnerships. The Homeless Prenatal Program is a good example. A strong local leader was recognized by four foundations in San Francisco who brought the nomination forward with matching dollars, which makes The Robert Wood Johnson Foundation only one of many funders. Our role was to be part of the root money for this program. We went there when the seed of an idea had already been planted. We were able to provide it with half of a stable funding base for four years. When we left, the root system was in place, and the program has continued to blossom.”

Seitz recalls, “I was impressed by this grant proposal from the beginning. They not only met the programmatic criteria, but there was also a certain spark to their plans that I recognized as a strong local initiative. Most powerfully, what I heard in that application was the authentic voice of the community being served.”

The proposal requested a $325,000 matching grant over three years in order to pursue a list of specifically defined objectives, among which were the following:

At the time of the application, the staff of the Homeless Prenatal Program consisted of Ryan, an administrator, three social workers, and three community health workers—almost all part-time. As a supplement to the San Francisco Foundation grant, the program had received the Intensive Care for Our Neighbor, or ICON, Award from the St. Joseph Health System in Orange, California. In addition to a significant financial boost, this award gave special recognition to the program’s efforts, since it was given to only three organizations nationally that serve marginalized and underserved communities. As explained in the 1992 proposal, the Homeless Prenatal Program was limited in its initial efforts: “Over the past two years, the Homeless Prenatal Program has provided basic prenatal assessment, group and individual counseling, referral for full-scale prenatal care, including care for high risk women, substance abuse counseling and a host of other necessary services.”

Despite an admitted failure of data gathering (notes were kept on four-by-six file cards in a box), the two-year pilot period of prenatal services to homeless women had generated encouraging results. Of the twenty women who gave birth in the first ten months of 1990, 90 percent delivered babies of normal birth weight, and 50 percent of those mothers who had previously been substance abusers delivered drug-free babies. In the first ten months of 1991, thirty-three mothers gave birth in the pilot project, with 91 percent of babies having normal birth weight and 70 percent of babies drug free.

Once the Robert Wood Johnson Local Initiative Funding Partners program’s matching grant for $325,000 was approved, the Homeless Prenatal Program moved quickly to accommodate a larger staff, to put better financial controls in place, and to reconsider the organizational structure. “During our initial site visit, we urge each of our projects to develop a strategic business plan, and we provide technical assistance,” Pauline Seitz notes. “Almost every small nonprofit needs to do work in this area. I know that business planning was particularly helpful to Martha in thinking through the growth of the organization.”

Martha Ryan agrees. “In 1992 there were three of us sort of running the Homeless Prenatal Program as a triumvirate,” she recalls. “The three were Marian Peña, an ex-nun and very committed social worker, Julia Velson, who was our first administrator, and myself, as our nurse practitioner. For about a year we shared decisions, but the board felt that there should be a central person to be in charge. It was really my vision, so I became the administrator. I was not entirely comfortable in that role because I don’t like conflict and I am troubled if I hurt people’s feelings by disagreeing, but I’m getting better at it.”

During Ryan’s ten years as a nurse, she had made intermittent trips to do relief work in Africa, eventually returning to the United States with the intent of becoming a nurse practitioner so that she could work in maternal and child health programs in the developing world. Even as she formulated her ideas for prenatal care of homeless women in San Francisco, her thoughts had turned to Africa. “When I had been in Sudan and Somalia, we trained local women to be the health care providers of the community because they were able to reach the other women and the families we needed to treat,” she says. “They really made the difference in preventing epidemics and getting health care to the entire village because they were trusted. I saw the same opportunity in San Francisco to educate formerly homeless women to be community health workers. They had the same knowledge of the homeless ‘villages’ and could develop trusting relationships far more effectively than health care professionals just walking into the situation. As a bonus, they got some work experience and some self-esteem and the feeling of giving back to their communities. So I decided to model my program after the work I had done in Africa.”

On Market Street the Homeless Prenatal Program became more proactive. With three community health workers recruited from the ranks of former clients, Ryan went to the shelters, to the hospitals, to the single-room occupancy hotels, to the bus stations, and to the streets of San Francisco. She found homeless pregnant women who would not go to anyone “official” for help because they were afraid that the Child Protective Services would take their children away. She found immigrant women with citizenship problems that prevented them from seeking assistance. She found women with substance abuse, psychological, and domestic violence issues. Most important, she found women who were ignorant about pregnancy and child care and ignorant of the services and agencies available to help them. In her own assuring, nonjudgmental way, she and her community health workers allayed the fears of these women, found them food and housing, and developed an ongoing relationship of trust and counseling. Those relationships allowed the clients to break away from their self-destructive habits and to raise healthy families.

“I asked my staff—women who were formerly homeless—to make presentations at the San Francisco hospitals and clinics,” Ryan says. “They talked about what it was like to come into the clinic and have somebody snub them or have someone look at them and start second-guessing who they were without trying to know them. It worked well to get clients referred to us and gave a little sensitivity training to the hospital staffs.” Quickly, the program had dozens of clients, and by 1994 it had 142 women as clients, 110 of whom were pregnant. That year, the program also hired Ramona Woodruff, who had been one of the Homeless Prenatal Program’s first clients and had gone on to work for the program, to be the full-time supervisor and trainer of the community health workers.

As the Homeless Prenatal Program developed, it began to work more closely with other providers of services for homeless women and began to advise women on possibilities for improving their lives. “The Homeless Prenatal Program is one of the best organizations we work with,” says Mildred Crear, director of maternal and child health for the City and County of San Francisco. “They are able to locate pregnant women and gain their trust in ways that government agencies have not been able to do. By bringing their clients to the appropriate agencies for food, housing, and health services, the Homeless Prenatal Program allows us to help homeless and needy people early with preventive medicine and education so that they do not develop more serious and more expensive medical problems later. They have also helped us to improve our services. We administer a federal supplemental food voucher program called ‘Women, Infants, and Children,’ or WIC, and one of the first things Martha pointed out to us was that these women had little or no access to food storage. Significant portions of large containers of milk and bread and cheese would go to waste, because pigeons would eat food left on window sills for refrigeration, or milk would go bad inside, or rats would find food before it could be consumed. We were able to work with the state to have the WIC packets resized so that families could have fresh food more frequently.”

“From that experience,” Crear explains, “we looked around at the state level and realized that other counties in California didn’t have any programs like Homeless Prenatal Program. In 1995, we implemented a Homeless Prenatal Conference, cosponsored by five counties who network and share resources for homeless women and families. The conference has met successfully for the past seven years. Also, I have now been able to provide a public health nurse to be housed at the San Francisco Department of Human Services, so that every pregnant woman who comes in to sign up for benefits is interviewed and referred to Homeless Prenatal Program, as well as to our services.”

By the spring of 1994, the Homeless Prenatal Program had grown to a staff of twelve, with five community health workers who worked with clients on a daily basis. All of the community health workers were being trained by a full-time health educator, with instruction in the prevention of sexually transmitted diseases, medical risks during pregnancy, family planning, and mental health techniques. They also learned peer counseling, computer skills, résumé writing, interviewing techniques, and other employment preparation skills.

According to the National Clearinghouse for Alcohol and Drug Information, “Data from one study of 36 hospitals, mainly in urban areas, were extrapolated to arrive at an estimate of 375,000 infants exposed in utero to illegal drugs each year, or 11 percent of all births.”⁶ Despite this real problem, there were no treatment programs available to women.

Ramona Woodruff, the supervisor and coordinator of community health workers at the Homeless Prenatal Program, had played an important role in advocating for programs to assist drug-addicted pregnant women while she was still one of the program’s early clients. “We had not really looked into the relationship between the use of crack cocaine and high-risk pregnancy until the late 1980s,” says Catherine Dodd, a nurse who was the director of women’s services at San Francisco General Hospital in 1988, when she met Martha Ryan. (She is now an assistant to Representative Nancy Pelosi.) “We knew about fetal alcohol syndrome, but this was new. I suggested that a group of perinatal advocates go to Sacramento to explain the problem to our elected officials.”

“In 1989,” Dodd recalls, “Martha, Ellie Journey from the March of Dimes, Ramona Woodruff, and I met with Jackie Speier, who was then an assemblywoman and is now a state senator. Ramona spoke emotionally about her struggle with crack cocaine addiction. She had been sober for ninety days at that point, and the Homeless Prenatal Program had given her hope and changed her life. Speier was deeply moved and immediately picked up the telephone and spoke with the governor. She said, ‘We must do something about prenatal substance abuse. It is inexcusable that all of the substance abuse programs are targeted at men and all of the federal funding is targeted at men.’”

Speier wrote and sponsored a bill, Alcohol and Drug Affected Mothers and Infants, which was signed into law by Governor George Deukmejian on September 30, 1990. The law created the Office of Perinatal Substance Abuse within the state Department of Alcohol and Drug Programs and an interagency task force to address the needs of substance-abusing pregnant women.

With state drug treatment programs in place, one of the first extensions of its work with homeless women that the Homeless Prenatal Program was able to develop was the Substance Abuse Services Project. A successfully recovering client, Carla Roberts, was hired to work as a case manager at the program. She was particularly effective in dealing with women who had substance abuse problems. “I got pregnant at seventeen and managed to graduate, and all of that time I was smoking marijuana and selling crack cocaine,” she says. “I felt especially bad because I had both of my parents still together and they had stressed the importance of education to their kids. I was still with the guy who had fathered the baby and was starting to take certified nursing assistant classes. I thought I had it together. Eventually, I ended up staying up late getting high on crack cocaine with my own customers, the people I used to feel sorry for. So from there, my whole life just spiraled downhill.” Roberts was arrested a number of times on drug and petty theft charges. Fortunately for her, a judge in San Mateo County decided to mandate her to do a year in a drug treatment program instead of six months in jail. The program was called Mothers and Infants Aligning, or MIA, and during the eighteen months at MIA House, Roberts was sent to the Homeless Prenatal Program for counseling. As she continued in the program, she was selected for training as a community health worker and came to work at the program.

“Carla actually went on to become an AmeriCorps volunteer with the Homeless Prenatal Program after she finished her training and became a full-time community health worker. As an AmeriCorps volunteer, she developed a program to help women who were trying to get into drug recovery programs. It was her brainchild, and when her two-year commitment came to a close, she continued on with the Homeless Prenatal Program, overseeing the program as a full-time case manager,” Ryan recalls.

Roberts told Ryan that addicts had an especially difficult time obtaining help from government agencies because the system seemed to be set up to discourage them more than to assist them. Roberts pointed out that these women were required to bring government-issued photo ID, find their birth certificates, provide cash or Medi-Cal papers, stand in long lines all day, only to be told that they were in the wrong line, and check in every day on the telephone. “Before I agreed to start our own substance abuse services project, I actually went down to stand on the line myself at the San Francisco Department of Human Services,” Ryan recalls. “The people were very slow and impersonal. Now, I’m a white woman and not a drug user, but that made no difference. They didn’t care. I have been there many times since trying to help clients to obtain benefits, and they have not become any less impersonal. Virtually the only way an addicted woman, already living a chaotic life, could jump through the hoops required to enter a government drug recovery program would be if someone helped her.”

This is what the Homeless Prenatal Program’s Substance Abuse Services Project does. It is now composed of four women, including Roberts, who help addicted women to understand the diversity of drug treatment programs that are available and to find one that they are willing to enter. In addition to the preparatory paperwork and communications obligations, the staff of the Substance Abuse Services Project realized that most of these drug treatment programs require financial contributions to the cost of treatment. They have been working to provide clients—who are usually jobless as well as homeless—with employment opportunities. Private meetings with case management workers are supplemented by weekly support group meetings for women to meet others who are dealing with similar problems.

“One aspect of the Homeless Prenatal Program’s development has been the growing awareness that homeless motherhood is not a single, simple issue. It is a complicated collection of problems,” says Nancy Frappier, coordinator of the program’s Perinatal Services Project. “Martha quickly understood that in addition to prenatal care, homeless pregnant women need help to continue to care for the baby after birth. In 1995 she conceived of what she called the ‘Aftercare Project,’ obtained a three-year grant under the Opening Doors Project, and hired me.”

Opening Doors: Reducing Sociocultural Barriers to Health Care was a joint program, established in 1992, of The Robert Wood Johnson Foundation and the Henry J. Kaiser Family Foundation. The foundations allocated $5.5 million to focus on ways to provide health care to people with issues of culture, language, race, or ethnicity. In their call for proposals, the two foundations noted that “even when health care is available and affordable, certain groups face non-financial obstacles to care, resulting in poorer access to care and health outcomes among racial and ethnic minority groups in the United States.” The Perinatal Services Project, which primarily connected impoverished or homeless black and Hispanic families to health care and parenting services, fit the Opening Doors requirements. Although funding from the two foundations ended, the Homeless Prenatal Program has continued the Perinatal Services Project with funding from other sources.

“Our focus is working with a pregnant woman in her last trimester of pregnancy and then after the birth of the baby,” Frappier notes. “We support these women in having healthy families, and we try to work with them until the child reaches the age of five.” The program offers an ongoing series of training sessions for baby care, parenting, and prenatal education. Case management counselors assist new mothers in obtaining cribs, baby food, breast pumps, diapers, and other basics for newborns. In many instances, case managers also act as liaisons or advocates for clients with the Child Protective Services or court systems. In addition to Frappier, there are two staff members and student interns from San Francisco State in the social work program and volunteer nursing students.

One component of the Opening Doors proposal was the establishment of a Policy Advisory Group, a panel that shared information about homeless prenatal care with other groups and tried to provide information for policymakers. “Most direct service organizations don’t make policy at all, but part of my background was the political action side, so I was attracted to this immediately,” Frappier says. “I felt excited about bringing those things together”—service and policy change. The Policy Advisory Group evolved into the Advocacy/Policy Program, which continues to inform legislators and health care policymakers on homeless family issues and also works on individual cases. One of the most important victories for the policy group was an allocation of $360,000 by the San Francisco Board of Supervisors to replace housing funds for homeless families that the federal government had eliminated.

As the Homeless Prenatal Program grew larger and reached out further into the homeless community with its programs, members of its board, Local Initiative’s Pauline Seitz, and other supporters were urging Martha Ryan to step up to another level of professionalism in management, fundraising, and business organization. As a result, in the mid-1990s, the program added new board members from the private sector. One of the new members was Gil Fleitas, a real estate executive. “My business partner, Steven Mavromihalis, who was president of the Homeless Prenatal Program’s board, asked me to join the board shortly after I moved from New York to San Francisco,” Fleitas recalls. “After attending board meetings for about a year, I began to question what I was doing. I was very successful in my professional career, but I wasn’t doing anything to make the world a better place. I wasn’t feeling fulfilled. In the summer of 1998, I made the decision to devote myself to volunteer work, primarily with Homeless Prenatal Program. Shortly thereafter, Steven asked me if I would consider taking over as president of the board.”

Fleitas, a soft-spoken man with a genial manner, set to work bringing the tools of private sector management into the Homeless Prenatal Program—“without destroying the culture.” Gently strengthening concepts such as financial discipline, strategic planning, succession planning, and measurement of results made the Homeless Prenatal Program a stronger organization. “There were a couple of board meetings in which some people were horrified that I would even mention such issues,” Fleitas recalls. “I assured them that if we didn’t ask the hard questions of ourselves, the people who were funding us would ask them.” Both Fleitas and Ryan admit that there was a clash between the older board members with strong feelings about protecting the character of the Homeless Prenatal Program and the new, business-oriented members. Thanks to Fleitas’s patience and willingness to compromise, the board members navigated through some contentious meetings to find agreement. In 2000, the fourteen-member board won the Lighthouse Award for excellence in nonprofit management from the Management Center in San Francisco.

Perhaps the most daring step in a series of innovative programs at the Homeless Prenatal Program is the Jail Outreach Project. The problem being addressed is a daunting one. Women are the fastest-growing segment of the incarcerated population.⁷ The number of women in California prisons has tripled over the past decade. The national female prisoner population has more than doubled since 1990. Women are the least violent component of the inmate population. More than 85 percent of women in jail are charged with nonviolent offenses. Women incarcerated for domestic violence offenses are frequently charged with fighting back against an abusive mate.

Carla Roberts, the initiator and administrator of the Substance Abuse Services Project, had many discussions with Martha Ryan about the damaging effects on homeless women of jail sentences for minor offenses, and she spoke from experience. After Roberts pointed out that the moment of release from jail was a window of opportunity for a woman, much like pregnancy, Ryan sought another grant from The Robert Wood Johnson Foundation’s Local Initiative Funding Partners program—this one to help 1,050 incarcerated women who are making the transition from jail back to society. The Knossos Foundation nominated the Homeless Prenatal Program for a Local Initiative program award, and, in 2000, the program received a three-year $314,000 matching grant. This time The Robert Wood Johnson Foundation partnered with the Knossos Foundation, the San Francisco Foundation, the VanLobenSels/RembeRock Foundation, the Zellerbach Foundation, and the Tesuque Foundation to provide matching grant dollars.

According to Pauline Seitz, “The Homeless Prenatal Program is unusual in having been awarded two different grants. Out of the two hundred programs that have been funded by the Local Initiative program between 1988 and 2002, only two have been funded twice. In each case, they returned for funding of a project that was completely different from the initial application.”
The proposal’s executive summary succinctly relates the problem addressed by the new project:

Every year approximately 750 women pass through the portals of the [San Francisco] County Jail. Of these women, 88 percent (660) are homeless and approximately 6 percent are pregnant. According to the Discharge Planning Unit, 90 percent (675) are in jail as the result of behavior that stems from substance abuse. Most are mothers. At the present time, there is virtually no safety net for women exiting jail. Furthermore, because of overcrowded conditions, women are released at all hours of the night. With no place to go, the incidence of recidivism is high.

The caseworkers hired for the Jail Outreach Project are all formerly incarcerated women in recovery, and they are strongly motivated to provide the support that in many cases they never got. There are three primary aspects to their work: first, persuading women in jail that there is an alternative to their previous lives; second, providing transportation by taxi on the night of release and prepaying one night’s lodging at a single-room-occupancy hotel two and a half blocks from the Homeless Prenatal Program’s office with a twenty-four-hour front desk so the released prisoners have somewhere to go; and third, following through with support once a released woman comes to the Homeless Prenatal Program.

The Jail Outreach Project has performed well in the second and third parts of this effort by finding food, housing, and medications for newly released women, as well as arranging pretreatment counseling, referrals to health services, a weekly support group for addicted women, and a bimonthly writing workshop. However, convincing newly released women to take advantage of this opportunity to find a new direction in life has proved to be surprisingly difficult.

“We go into the jail twice a week—me, Lupe, Judy, Karen, and Giannina,” Roberts says. “When I first started to work in the jails seven years ago, I was seeing women who were between twenty-nine and forty-five. Now, it’s eighteen, nineteen, or twenty. These young women are usually very alone and very afraid. We reach out to them and offer a helping hand. If we can make a connection with these women and get them to come to us at the end of their sentence, they have a good chance of staying out and starting a new life. But we see too many who don’t take our help and just keep going back to jail. When we talk with the women in jail, we ask what their needs are, what it would take to prevent them from coming back. If they come to us when they get out, we help them to find housing, food, and employment. We go with them to parole meetings or court hearings. It is particularly difficult if a woman has a drug felony because then she is not eligible for public housing, welfare, or financial aid for education. There is a stigma that prevents them from applying for most normal employment. They are getting double the punishment.”

Despite its efforts to break the chain of recidivism, the Jail Outreach Project has encountered more resistance to its outreach than it anticipated, and both Ryan and Roberts admit that they have not met their self-imposed goals. “The relationships with boyfriends or drug-oriented social groups that often may have landed these women in jail in the first place are strong ties,” Ryan says. “Stronger than we realized. We were too optimistic in our projections of how many women would accept our offers of help. We’ve developed a good working relationship with the Discharge Planning Unit of the county jail, and we have had success with women who come to us. But too many of these women are into a cycle of hopelessness that we have to figure out how to break.”

In fifteen years of development, the Homeless Prenatal Program has grown from that closet in the Hamilton Family Center to an effective outreach program for homeless women in the San Francisco area. Despite her accomplishments, Ryan has bigger plans yet. “One of my goals is to create a community center where families can come into one place and have all of their needs met,” she says. “I want it to be a real public and private one-stop partnership so that representatives from the state and city agencies
for the poor can meet their clients in one building. We will provide family counseling, housing assistance, substance abuse services, perinatal classes—all of the work we are already doing. I’d like to see legal services and immigration help and computer training and child care and exercise classes. Most of all, I would like to establish a community health clinic in the building where families can get simple health care services and prenatal examinations. It would be a place where children could get vaccinations and adults could have mental health services. I’d like to run that clinic.” She stops for a few moments and then turns back to reality. “We’ve already got a design and a property. Now, all we need is $6 million to build it.”

Gil Fleitas added another, perhaps more important, goal. “When I first joined the board of the Homeless Prenatal Program and saw what they were doing and saw how effective it was and saw the difference that it was making in people’s lives, the first thought that popped into my head was, ‘What a shame that it is only here. Why can’t this be elsewhere?’” Although many urban areas have family shelters, homeless prenatal programs, family counseling centers, low-cost housing programs, drug treatment centers, and other services, nowhere outside of San Francisco’s Homeless Prenatal Program is there a comprehensive service and support system for women and families in crisis. Ellen Bassuk, of the National Center on Family Homelessness, observes, “I am not aware of another program with the comprehensive scope of services that the Homeless Prenatal Program provides. I wish there were many of them.”

According to Pauline Seitz, the issue of re-creating some of the innovative programs from the Local Initiative program’s grants has grown in importance for her, too. “The Local Initiative grants come to us because they are strong models in their communities. Many of them are led by passionate, charismatic leaders like Martha Ryan, who seem to be one of a kind in their energy, dedication, and vision. But we need to learn how to disseminate what they do.”

When Fleitas became president of the Homeless Prenatal Program board, he strongly recommended to Ryan that she have a succession plan and that she needed to codify the intervention techniques of her community health workers. “I said to her, ‘You’ve created this wonderful organization with concepts and operating principles and a culture that works. Why not figure out how to make it work in other cities? Why not figure out how to put the Homeless Prenatal Program in a box?’” he recalls with a laugh. “We may never find another Martha Ryan, but we can teach others how to do what you have done.”

“I’ll never forget the first time Gil talked to me about this issue,” Ryan says. “I was taken aback. My first thought was that I must have been doing an inadequate job. But when I calmed down, I realized that he was absolutely correct—a good leader is only as good as the organization is when he or she is gone. Not only should this organization continue and thrive if anything ever happened to me, I would love to share what we have learned. I would love to see the Homeless Prenatal Program replicated all over the world. We have been working on succession planning and writing down the steps we go through with our clients and the lessons learned. We still have a long way to go. And I have added another goal to my dreams for the future of Homeless Prenatal Program. Someday I want to see one of our former clients, a woman from the streets or the jail, become president of this organization. That’s really when we will have achieved a big victory for homeless families.”