RWJF Scholar examines neighborhood-based death rates from opiate-based painkiller overdoses, compared with heroin overdose deaths.
Union Mission, a nonprofit organization in Savannah, Ga., operates a health care facility that provides a range of outpatient and inpatient services to the local homeless population. The facility named the J.C. Lewis Health Center is part of an integrated system of homeless assistance programs offered by Union Mission in collaboration with other community groups and government agencies.
Two competing hospital organizations Memorial Health University Medical Center and St. Joseph's/Candler Hospital System helped develop and support the health center and related shelter clinics.
The Robert Wood Johnson Foundation (RWJF) helped provide the center's start-up funding with a $475,000 grant awarded through its RWJF Local Funding Partnerships. Local Funding Partnerships is a national matching-grant program that seeks to stimulate innovative, community-based projects to improve the health and health care of underserved and vulnerable populations.
Russell Smith's life in Savannah, Ga., fell apart when his wife of 24 years died in July 2001. He couldn't keep his mind on his job of washing trucks, he says, and soon found himself out of work and homeless. He had some family a stepson and a brother but they didn't care much about him, at least not in his view. At age 59, Smith was living on the streets, feeling depressed and thinking about hurting himself.
Fortunately, his slide didn't go too far. When Smith asked a Savannah policeman where there was a shelter, the officer took him to the J.C. Lewis Health Center. Located on the west side of the city's historic district, the Lewis center provides a range of inpatient and outpatient health services specifically for the homeless.
Russell Smith was a beneficiary of the center's holistic approach. Like many homeless people, he had not one problem but a series of physical and mental difficulties including diabetes and high blood pressure. Also like many homeless, he had no one to help him get on top of his troubles. The J.C. Lewis Health Center became Smith's support system.
In addition to providing a respite bed, medicine and counseling, the staff arranged for Smith to be evaluated at a psychiatric hospital, helped him apply for Social Security disability, and instructed him in life skills and behavioral health issues.
After four months at the center, he was ready to move across the street into Grace House, a 50-bed shelter for homeless men operated by Union Mission, Inc., the same nonprofit organization that runs the health center. At Grace House, Smith eventually became an unpaid assistant, acclimating newcomers to the shelter, administering drug tests and overseeing the volunteer work schedule.
Sitting in one of the health center's conference rooms on a warm August afternoon in 2003, Smith explained that although short of perfect, his life now seemed to be back on track. At times he still felt depressed, he explained, and a stroke had recently sent him to the hospital. But now on an antidepressant and an antipsychotic, he no longer had a desire to harm himself, he said. His expectation was that he would leave Grace House and get a place of his own once his disability payments began.
But Smith said even then he will continue coming to the health center for counseling, prescriptions and other support. "They make sure I get to the doctors on time."
A major portion of the start-up funding for the J.C. Lewis Health Center came from RWJF though its matching-grant program, called the Local Funding Partnerships. By collaborating with community foundations and other givers across the country, Local Funding Partnerships seeks to stimulate innovative, community-based projects that improve the health and health care of underserved and vulnerable populations.
The story of the J.C. Lewis Health Center illustrates how this cooperative approach can make a significant difference in people's lives, including people on the fringe of society.
Union Mission began in 1936 as an evangelical relief organization, providing food and shelter in response to Great Depression conditions in Georgia's historic, handsome port city of Savannah. In the 1960s Union Mission closed its shelter operation, but two decades later a Savannah businessman, philanthropist and former mayor named Julius Curtis Lewis Jr. made a proposal that revitalized the organization. If Union Mission would work to end homelessness in the city, he would invest his money in the task.
Lewis's commitment was followed closely by a second key development at Union Mission: the hiring in 1987 of a young, energetic Baptist minister to run the organization. Michael Elliott president and CEO of Union Mission earned his undergraduate degree in history at Georgia Southern University and master's degrees in divinity and social work at the Southern Baptist Theological Seminary in Louisville, Ky. While in Louisville he was pastor of an inner-city church and headed the Louisville Coalition for the Homeless.
Along with an outgoing personality and a zeal for assisting the needy, Elliott returned to his native Savannah with a conviction that a nonprofit must act in many ways like a corporation if it is to be successful. "While I'm a nonprofit, I'm a nonprofit business," says Elliott, a devotee of management guru Peter F. Drucker and a strong believer in setting outcome performance measures. "How do you establish a bottom line in a sector where there isn't one?" he asks.
Fueled by Lewis' and Elliott's leadership, Union Mission developed a steadily increasing menu of initiatives to help Savannah's homeless population, often in collaboration with other organizations, both private and governmental.
After starting Grace House, Union Mission opened a 65-bed facility for homeless women and children, a transitional housing program for female substance abusers, and a complex of buildings that provide housing and health services for people impacted by HIV/AIDS. Today, Union Mission facilities have about 350 beds for the homeless almost half the city's total shelter space. (Savannah as of 2003 had a total of 765 beds and on any one night about 1,000 homeless people, according to Elliott. While the bed count falls short of need, Savannah is doing more to meet the homeless problem than many communities, he says.)
Elliott and his staff, however, are not interested in just beds. Union Mission, which has shed its original religious orientation, implemented a number of counseling, training and employment programs aimed at making the homeless self-sufficient. Case managers assess the needs of the shelter residents and attempt to match them with appropriate assistance. One option, for example, is an 18-week cooking course developed by Union Mission in cooperation with Savannah Technical College. The curriculum aims at placing homeless and low-income people in local restaurant jobs with hourly pay in the $7$9 range.
Elliott says there are many reasons for homelessness from individual problems, such as substance abuse and a lack of life skills, to societal changes, such as the shift to a service economy. Just as there is no single cause of the problem, there is no single solution, he says. What is needed is a combination of approaches, which is what Union Mission is attempting to provide.
Savannah's total number of homeless over a full year dropped from 6,511 in 1992 to 2,795 in 2000 and then jumped up to 4,011 in 2002, according to Elliott. Despite the recent increase which Elliott attributes to the nation's economic downturn he says the community deserves credit for making progress.
Through its work, the Union Mission staff became concerned about the homeless population's lack of access to primary and preventive health care. Typically, Savannah's homeless were getting medical attention only after a health problem blossomed into a crisis necessitating hospital emergency room or inpatient treatment.
Also, without a health care capacity of their own, local shelters had trouble handling homeless patients who were discharged from a hospital but still needed assistance to recover their health. Elliott says he became aware of this problem when he began noticing shelter residents in slings and with other obvious physical problems. "I said 'You're too sick to be here. You ought to go a hospital.' They said 'The hospital sent us here.' This is when I first heard of hospital dumping."
Another health concern was the high incidence of substance abuse and mental illness among the homeless. In 1997, 44 percent of the Grace House residents had a history of either one or the other.
In response, Union Mission collaborated with two Savannah hospital organizations to develop a health care system for the homeless. The plan called for initiating primary care clinics within several existing shelters and developing a stand-alone health care facility for the homeless that would include a primary care outpatient clinic, inpatient beds, detoxification services, and a mental health assessment and intervention capability. Some of the beds would provide respite care for people too physically or mentally ill to be in a shelter but not sick enough to be hospitalized, and some would be reserved for short-term residential psychiatric treatment and detoxification from drugs and alcohol.
Elliott argued that the initiative would save the hospitals money by reducing the amount of uncompensated care they provided to the indigent. Both hospital organizations Memorial Health University Medical Center and St. Joseph's/Candler Hospital System (two hospitals operating together) agreed to help fund the plan's implementation.
Union Mission began holding primary care clinics on a rotating basis at five facilities two run by Union Mission and three by other organizations (the Inner-City Night Shelter, a Salvation Army shelter, and the Social Apostolate soup kitchen, an activity of the Catholic Diocese of Savannah). Staffing the clinics were a family nurse practitioner, a registered nurse, a licensed practical nurse and two licensed professional counselors.
For the free-standing health care facility, Union Mission acquired an old commercial building at 125 Fahm Street just across the street from the structure that holds the Union Mission office, Grace House, and the Magdalene Project, Union Mission's shelter for women and children. Funding for the building's purchase came from the J.C. Lewis Family Foundation, the U.S. Department of Housing and Urban Development, and the state of Georgia.
The Lewis foundation also contributed $250,000 for the building's renovation and underwrote the architectural fees. Each of the two hospital systems contributed $100,000 in construction money as did Robert S. Jepson Jr., a Savannah philanthropist. The renovated building named the J.C. Lewis Health Center opened in August 1999.
In addition to the construction money, Memorial committed $267,500 over 18 months to help staff the shelter clinics, and St. Joseph's/Candler gave $100,000 for startup costs of the new facility. However, Union Mission needed additional funding to fully staff the health center. In November 1998, the organization applied to Local Funding Partnerships for a four-year grant to support an additional nurse practitioner, three additional licensed practical nurses and one medical social worker.
In developing the health care initiative, Elliott visited a Jacksonville, Fla., clinic for the homeless that had previously received Local Funding Partnerships funding. "We stole blindly from what they had done and tried to build on it," Elliott says. One difference was that the Jacksonville project the I.M. Sulzbacher Center for the Homeless (ID# 029809) had outpatient services only.
The Local Funding Partnerships national program office staff considered the Union Mission proposal a strong one. It represented an unusual effort to join two hospitals in a health promotion/disease prevention program for the homeless. Also, the application projected annual savings of $17 million in uncompensated care enough that Union Mission predicted the two hospital organizations would sustain the initiative after the RWJF grant ended.
The four-year, $475,000 RWJF grant (ID# 037327) began August 1999. In addition to the money, Elliott says the show of support by a large national philanthropy helped generate additional local backing for the project. "It really galvanized the health care community; it really legitimized what we're doing."
Local Funding Partnerships requires that other supporters match the RWJF funding dollar for dollar. The Union Mission project exceeded that requirement by a significant amount. At the end of the grant period, Union Mission reported the J.C. Lewis Health Center and related programs received about $4 million from other sources, including contributions from the two hospital partners that went well beyond their initial donations. (See Appendix 1 for the full list of funders.)
"I don't think a homeless shelter should look like a homeless shelter." That's Elliott's philosophy, and it is reflected in the interior of the J.C. Lewis Health Center. The reception room looks like a private doctor's office; what look like oriental rugs spot the shiny wood floors, and there are pictures of garden scenes on the dark-gray walls. Patients wait in comfortable sitting chairs, and the receptionist presides from behind an impressive desk.
"We want this to be a place we would like to come for our health care," says Melanie Finocchiaro, who directs the center's primary health services staff of 18 to 20 full- and part-time workers.
Finocchiaro, a registered nurse and family nurse practitioner, worked at St. Joseph's Hospital before joining Union Mission in March 1999. In addition to administrative and clerical personnel, her staff includes two other family nurse practitioners, an adult nurse practitioner, six licensed practical nurses, four patient care technicians, and a dental hygienist. The center can provide patients on-site access to a family practice physician, an internist, an orthopedist, chiropractor and optometrist. A county health department physician provides medical oversight.
Finocchiaro's staff holds primary care clinics at the J.C. Lewis Health Center every Monday, Wednesday and Friday. In addition, regularly-scheduled outreach clinics continue at two homeless facilities: the Social Apostolate soup kitchen on Tuesday and the Salvation Army shelter on Thursday. (The clinic at the Inner-City Night Shelter stopped after two years as a result of physical and programming changes at that facility. Residents of the Union Mission's own shelters come to the health center, which is in easy walking distance.) The staff holds clinics at other facilities in Savannah on request and provides off-hours services to accommodate clients who work and are unable to make the scheduled clinics.
Health problems treated by Finocchiaro's staff include upper respiratory tract infections, hypertension, diabetes, influenza, strep throat, ear and eye infections, feet ailments, malnutrition, anemia and gynecological problems. The staff also tends sprains and wounds and performs HIV testing.
The health center has two dental chairs, and staff dental hygienist Ellen Nuske coordinates a full range of dental services provided by local dentists and other dental professionals on a volunteer basis. Patients with poor eyesight get glasses through a local vision center.
In addition to Finocchiaro's staff, Union Mission assembled a seven-member team to deal with mental health and substance abuse needs under the direction of Regina Smith, a licensed professional counselor previously in private practice. The team includes a licensed clinical social worker, a registered nurse specializing in psychiatric/mental health care, a group facilitator, and a part-time epidemiologist handling AIDS prevention and education. A psychiatrist provides part-time assistance.
The J.C. Lewis Health Center's inpatient program underwent a number of changes in the course of the RWJF grant period. Union Mission planned for 32 beds, but the facility actually operated with only 22. The staff was not large enough to meet the state's required staff-patient ratio for the higher number, Elliott says. Also, the need for respite beds turned out to be less than expected while the demand for outpatient services has been greater than anticipated. If he were doing it over again, he would build more outpatient space into the center, says Elliott.
Initially, Union Mission leased 12 of the beds to another provider, the Gateway Community Service Board, for treatment of substance abuse cases. The arrangement proved unsatisfactory, and Union Mission subsequently turned its inpatient substance abuse services over to a newly formed organization called the Savannah Area Behavioral Health Collaborative. In addition to Union Mission, the collaborative includes Memorial Hospital, Recovery Place of Savannah and the Chatham-Savannah Authority for the Homeless.
In addition to treating physical, mental and substance abuse problems, the health center staff tries to guide the patients into educational, employment and counseling programs that will help them end their homelessness.
One of these is a horticultural therapy program designed to help the homeless deal with problems of self esteem and stress. The program started with an herb garden at Grace House and then incorporated a larger plot on the grounds of the Lewis health center. Later, the program named the Garden of Hope expanded further to include a two-acre parcel at an inner-city elementary school a half-mile from the health center.
A visitor to the schoolyard garden in August 2003 found Dave, a mentally retarded man in his 50s, carefully mowing the grass around the garden beds while a volunteer supervisor tended to plants. Elliott views the horticultural program as evidence that it is possible to create support systems to keep the mentally ill off the streets and also out of expensive institutions. "To me, it's community building."
In 2003, Union Mission enlarged the horticultural program further by opening a Saturday farmers' market on a downtown lot and collaborating with Savannah Technical College to develop a landscape training course. "Everyone wants to go high-tech, but there are some low-tech jobs where people can make very good livings," says Elliott.
The cooking course, which is also open to health center patients, is another effort to move the homeless into the workforce. In 2002 Union Mission strengthened this program by starting a restaurant where students can practice their new culinary skills in the real world. The Bread and Butter Café initiated in collaboration with a local food bank is open to the public for lunch weekdays 11:301:30. Students prepare an assortment of soups, sandwiches, pot pies and desserts. The café, designed to be an educational tool, does not make a profit. Nevertheless, the simple, pleasant 45-seat dining room located across the street from the new farmers' market does a steady business.
Despite significant financial support for the health center, Union Mission faced funding issues. Services provided to the homeless by the Lewis center go largely unreimbursed. About 20 percent of the patients are on Medicaid, according to Kelly McDaniel, the center's health services administrator. For uninsured patients, the center has a sliding fee scale. But, says Smith, the behavioral health director, "We have yet to have someone meet the scale."
The center buys medications through a local pharmacy at a discount rate; in addition, local physicians donate some medicine and pharmaceutical companies provide free samples. Also, the center staff helps patients order medicine through pharmaceutical company assistance programs. Nevertheless, pharmaceutical costs are significant.
Union Mission twice applied unsuccessfully to the U.S. Department of Health and Human Services for a grant for homeless health care. In addition to several hundred thousands of dollars, the grant would have made the Lewis facility a federally qualified health center the designation necessary for 100 percent Medicaid reimbursement.
The homeless health program suffered a serious blow in 2002 when St. Joseph's/Candler stopped its funding. Elliott, who promoted the health care center as an economic benefit to the hospitals, said he had expected a $250,000 donation from St. Joseph's/Candler in the upcoming year and called the decision "a shocker." However, St. Joseph's/Candler CEO Paul P. Hinchey told the Savannah Morning News that his hospital system never committed to continuous funding and that the cutoff should not have been a surprise. After four years of support, his organization had other community commitments to meet, Hinchey said.
Members of the St. Joseph's/Candler and Union Mission boards reopened discussion of the funding issue after the RWJF grant ended. The discussions were ongoing in early 2004, according to Elliott. Memorial's support for the center has continued without interruption.
In its final report to RWJF in August 2003, Union Mission reported the following:
In 2000 and 2001 Union Mission issued a detailed accounting of the impact of the J.C. Lewis Health Center and disseminated the data to local hospitals, funding sources and the community at large. Starting in 2002, Union Mission incorporated the Lewis health center performance data into the organization's annual report. The health center also received attention in various brochures, newsletters, videos and press releases disseminated by Union Mission and on the organization's Web site.
Elliott and other staff members made public presentations, including one to the 1999 annual meeting of the National Alliance to End Homelessness in Washington and another in 2000 at a regional conference hosted by the U.S. Department of Housing and Urban Development in Atlanta. Staff also addressed local civic, business and church groups.
Elliott is the author of more than a half-dozen books, including several about his experiences working with the homeless. During the RWJF grant period, he wrote a novel based on the establishment of the Lewis health center entitled Tour of Homes (Savannah, Ga.: Frederic C. Beil, Publisher, 2004).
Also during the grant period, Union Mission published a nonfiction book by Elliott Out from under the Rock: Reflections of a Minister at Large that draws on stories of Savannah's homeless. An article by Elliott "The Positive Economic Impact of Health Care for the Homeless" appeared in the spring 2000 issue of the Journal of the Medical Association of Georgia.
The Savannah Morning News ran numerous articles on developments and issues surrounding the Lewis health center, including formation of the behavioral health collaborative and the decision by St. Joseph's/Candler to cease funding the health center. The center also received coverage in other Georgia publications, including the Atlanta Journal-Constitution and the Augusta Chronicle, and on area television and radio stations. (See the Bibliography for details of some of these communications activities.)
Following the RWJF grant, Union Mission pursued plans to convert a commercial building located next to the health center into a facility housing the Savannah Area Behavioral Health Collaborative. The Lewis foundation bought the building formerly home to an appliance parts business in January 2002, and began raising funds for its planned $1-million rehabilitation. When complete, the building is to be the J.C. Lewis Behavioral Health Center.
Meanwhile, the collaborative expanded its activities by winning a contract to provide Chatham County (which contains Savannah) with adult mental health care as well as substance abuse services, effective January 2004. As part of this expansion, Union Mission enlarged its behavioral health team from seven to 27 members and transferred the entire team to the collaborative as staff. The additional 20 workers raised Union Mission's total employment to about 100 full- and part-time employees. Until the new behavioral health facility opens, the collaborative is providing services in several facilities in Savannah, including the Lewis health center.
In another development, Union Mission initiated a cancer screening, education and therapy program at the health center. The organization sought RWJF funding for the initiative but was not successful. Projects that receive grants through Local Funding Partnerships generally do not get additional money from RWJF.
In December 2003, Union Mission applied a third time for federal funding, and in the fall of 2004 its J.C. Lewis Health Center was awarded Federal Qualified Health Care status by the Health Resources and Services Administration. The center received $300,000 in annual funding, giving it the designation necessary for Medicaid reimbursement and the ability to compete for expansion grants. Center staff got signatures from all members of Georgia's congressional delegation on the cover letter for the application.
Comprehensive Health Services Program for Homeless People
Union Mission (Savannah, GA)
Melanie Finocchiaro, F.N.P., R.N.
Other Sources of Financial Support for the J.C. Lewis Health Center and Related Programs during the RWJF Grant Period
|Chatham County Health Department||$188,000 annually since 2001|
|Georgia Department of Community Affairs||$100,000 total|
|Georgia Departments of Community Health and Community Affairs||$26,000 total|
|HealthCare Georgia Foundation||$100,000 total|
|Memorial Health University Medical Center||$1.8 million total|
|Savannah Area Behavioral Health Collaborative||$450,000 annually since 2002|
|St. Joseph's/Candler Hospital System||$750,000 total|
|United Way of the Coastal Empire||$166,000 total|
|Miscellaneous community donations|
How the J.C. Lewis Health Center Has Made a Difference in People's Lives
Homeless people often suffer from a multitude of health problems, and treatment at the Lewis health center is seldom a simple proposition. The staff's response is to offer help and withhold judgment. "We treat everybody as a VIP pretty much, and that's why they are receptive," says Melanie Finocchiaro, who directs the center's primary health services. "We accept them where they are and go from there."
David Adams, 51, is a case in point. Adams, who is originally from Atlanta, explained in an interview that he has a long history of binge drinking, the binges lasting two to three days. His wife left him, his kids drifted away, and several years ago he moved in with his mother in Dublin, Ga. But then she became ill, and Adams' brother put her in a nursing home and put Adams out of the house because of his drinking.
Alcohol, however, was not his only problem. Years ago, Adams suffered serious injuries in a motorcycle accident and had to have his left foot amputated. Possibly as a result of walking with an artificial foot, he eventually developed a hip problem, he said. Also, in recent years his artificial foot broke, he got glaucoma, and he injured his right leg by spilling bleach on it while cleaning a bar.
That was the shape Adams was in when he visited Tybee Island outside Savannah to attend a party. After the party, a man he met there took him to downtown Savannah, where someone saw him limping and escorted him to the J.C. Lewis Health Center.
The staff at the center gave Adams medical attention and a bed. About a week later he moved across the street into Grace House, a shelter for homeless men. However, Adams soon took to the streets of Savannah, spending nights on a bench by the Savannah River. "I was still into my drinking," he explains.
Nevertheless, from time to time Adams would return to the Lewis health center for help, including glaucoma medicine. "I'd come back here because it's free," he said. But in addition to the glaucoma, the staff was addressing Adams's other health problems.
At the time of the interview conducted when he was once again at the Lewis center, this time for treatment of a new leg wound he had already been fitted for a replacement foot and was expecting the prosthesis to arrive any day.
Also, the staff was trying to help him get a hip replacement. And through classes he took at the center, he had become aware of the damage that alcohol does to the body. It had been eight or nine months since he had a drink, he said.
Adams did not know exactly what would happen to him next but said he was working on getting Social Security disability benefits and permanent housing. "This is a good clinic here. They've done an awful lot for me. An awful lot."
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Elliott M. Out from under the Rock: Reflections of a Minister at Large. Savannah, Ga.: Union Mission., 2002.
Elliott M. Tour of Homes. Savannah, Ga.: Frederic C. Beil, Publisher, 2004.
Elliott M. "The Positive Economic Impact of Health Care for the Homeless." Journal of the Medical Association of Georgia, 89: 1519, 2000.
Union Mission, Inc. 2002 Annual Performance Report. Savannah, Ga.: Union Mission, 2003.
www.unionmission.org. The Web site of Union Mission provides detailed information on the organization's services, including the purpose and activities of the J.C. Lewis Health Care Center and its related programs.
Report prepared by: Michael H. Brown
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: Jane Isaacs Lowe
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