Nurse Care Management

Beginning in 2017, the Community Foundation of Utah set out to answer a critical question: Could healthcare help solve homelessness? Through a $545,000 multi-year grant to Salt Lake City’s Fourth Street Clinic, the Community Foundation of Utah began a partnership that has broken barriers and blazed a trail in providing healthcare resources for those experiencing, or at risk of experiencing, homelessness in the Salt Lake Valley.

The Community Foundation of Utah’s Housing and Homelessness Fund awarded the grant to establish the Nurse Care Management program (NCM), which operates as a hub-and-spoke initiative to provide improved healthcare access to Salt Lake County’s housed homeless populations. With Fourth Street Clinic as the hub organization and five community organizations participating as the spokes, a groundbreaking collaboration began. The participating organizations include YWCA Utah, Housing Connect, First Step House, Volunteers of America Utah, and The Road Home

This grant allowed Fourth Street Clinic to hire nurses and community health workers to visit eight total homelessness provider sites within Salt Lake County. By bringing medical professionals to these sites, individuals receiving assistance from these organizations for other services would also have easy, on-site access to healthcare. Lack of transportation to a clinic and the crowded waiting rooms often cause many of these individuals to avoid or delay seeking necessary medical attention, meaning on-site healthcare has the ability to prevent serious medical emergencies and even death.

But how does healthcare access actually impact homelessness? Health-related incidents and issues can cause what is termed a “destabilizing exit” - a forced exit - from a shelter or permanent supportive housing. Someone battling drug addiction may seek refuge in a shelter but be turned away because he or she is under the influence of a controlled or illegal substance. A behavioral health issue could lead an individual to fight with neighbors, which may be grounds for eviction based on a housing facility’s code of conduct. In these cases, a medical intervention could reduce the risk of a destabilizing exit from a shelter or permanent supportive housing. Research shows that destabilizing exits can increase the risk of chronic homelessness. A medical intervention is an opportunity to not only tackle healthcare needs, but directly reduce homelessness through programs like NCM. 

Several months into the program, the Community Foundation of Utah met with all of the participating organizations and discovered that while the NCM program was successfully seeing many patients, the complexity of the model had made regular communication between nurses and case managers challenging and did not provide opportunities to discuss challenges together and innovate toward solutions. Believing that the NCM program had immense potential, the Community Foundation of Utah shared our concerns with partners at Salt Lake County. Salt Lake County connected the Community Foundation of Utah with a Harvard Government Performance Lab Fellow, Saskia DeVries, who had been assigned to work for Salt Lake County. Saskia was trained in facilitating discussions between multiple organizations under one contract, and was brought in to the NCM program to help jumpstart the process.

The Community Foundation of Utah brought stakeholders to the table to begin analyzing the program’s effectiveness and identifying gaps. Saskia became a crucial resource in facilitating discussions between the organizations and in tracking critical metrics of the program. By inviting a representative from each NCM service provider site to monthly meetings, the Community Foundation of Utah enabled these various organizations to explore new approaches to their work and fostered collaboration and the sharing of best practices. It was crucial to establish a safe space where new ideas, failures, and action plans could be discussed freely. Fourth Street Clinic’s Medical Director, Dr. Michele Goldberg said, “The Nurse Care Management program has brought all involved agencies together to brainstorm and determine what outcomes are truly important for this population. Having the whole group come together has really increased the enthusiasm and momentum for the project.”

As the meetings progressed, Fourth Street Clinic revamped their data collection and site staff enhanced communication processes with nurses. Within weeks, the data showed that more clients were receiving care across all sites and that 96% of visits with nurses required medical decision-making, demonstrating that the program was filling a gap that could not be filled with additional case managers only. Through regular data analysis, NCM is continually identifying gaps and potential improvements to ensure each site is effectively utilizing the provided nurses based on that site’s specific needs. “It’s been hard work,” says Dr. Goldberg, “But well worth it because of what we’ve accomplished so far.”

Collaboration has been the driving force for innovation in this program. NCM has implemented a new approach to healthcare access for clients by increasing communication between case managers and nurses, tracking crucial metrics to identify successes as well as areas for improvement, and facilitating ongoing healthcare coordination for clients.

Erin Blackford, Social Impact Analyst at the Community Foundation of Utah, has led the facilitation of the monthly meetings for the sites and emphasized the importance of collaboration. “When you are tackling a social issue, you need to collaborate. Pooling resources and sharing ideas is the only way you can make substantial progress. No single organization is going to solve homelessness on their own.” 

Increasing collaboration between case workers and nurses has also been essential to the program’s success. The program nurses and case managers at the various sites have been able to establish open lines of communication regarding client needs while respecting patient privacy. Through open idea sharing, they developed a plan to enhance their communication to improve the client experience. After receiving immediate attention from nurses on-site, clients need coordination for ongoing care in the broader healthcare system, which nurses provide by establishing them as a new patient and connecting them to doctors and specialists for future care.

However, the journey is far from over. In addition to implementing the NCM program in the new homeless resource centers, Fourth Street Clinic and the partner sites are beginning to evaluate trends in the use of emergency medical services (EMS) - also known as 9-1-1 calls - for the different sites. Looking at trends over time will help the NCM program identify other ways to meet the needs of clients and reduce unnecessary EMS calls, lessening the frequency of serious medical emergencies for the clients served while minimizing the financial burden on local government.

The Community Foundation of Utah is dedicated to building lasting relationships within the community we support by convening, collaborating and encouraging innovation. NCM is just one example of the Community Foundation of Utah’s commitment to impactful philanthropy now and for generations to come. Help the Community Foundation of Utah continue to support our community by donating to The Housing and Homelessness Fund or any of the organizations who participate in NCM (YWCA Utah, Housing Connect, First Step House, Volunteers of America Utah, and The Road Home).

 

A big thank you to the Housing and Homelessness Fund Advisory Committee for their leadership: Pamela Atkinson, Homeless Advocate; Preston Cochran, Executive Director, Shelter the Homeless; David Litvack, Deputy Chief of Staff, Salt Lake City; Erin Litvack, Deputy Mayor, Salt Lake County; Senator Ann Milner, Utah State Senate; Mikelle Moore, Senior Vice President of Community Health, Intermountain Healthcare; Tiffanie Provost, Owner, Axiom Properties, LLC; and Alan Pruhs, Executive Director, Association for Utah Community Health.