� Healthcare x Homeless Services - Working Slides.

Chattanooga: Aim Statement

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Project Selection

[August] Notes

• Hospital does not have the capacity to dedicate a person to fulfill this role,
• Could someone in CHI’s case management office to shadow and learn from this case conferencing?
• This role could support broader understandings of what it is like to work with individuals experiencing homelessness
• Betsy: Program for patients struggling with substance abuse where outside agency comes in to provide supportive care before discharge.
• Could somebody be on call from HRS serve in a similar capacity
• Data Sharing
• Need the capacity to install case conferencing to make this worthwhile
• Community will is there
• Sherry: How long is too long?
• FUSE was the original instance but they need better data matching
• FUSE is ramping back up – but need a better process
• Public Will
• Working on a campaign about how to get the stories out
• Messaging doc (Nicole Wilson) being provided for marketing team

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Click to see archive of older notes and working slides

This is a quote this is the important part of a quote maybe it has $778 numbers for our work. These partners are at the forefront of the conversation and offer instrumental thought leadership.

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January Agenda

• Welcome
• Pilot Update
• Workshop #3 will be rescheduled for early March 2022
• All Singles Scorecard
• Project Progress
• Updates since our last call
• What is going well?
• Where are we stuck?
• Where are we trying to go next?
• Next Milestones/Next Steps

[January] Notes

• Pilot Update
• Workshop #3 will be rescheduled for early March 2022 (1st -2nd 2-4pm ET
• All Singles Scorecard
• Project Progress
• Updates since our last call
• One partners facility burned down (Catholic Charities)
• Homeless health care clinic has been overwhelmed with Covid. The Community Kitchens director died.
• Welcome home respite is moving forward
• Need to have a role to be lead for real estate lead. Try to get 2-3 year grant to have real estate advisor to work with faith community. Meg to check in with CS real estate team for resources
• We need the actual housing
• Transitional housing - for veterans - GPD (keep them here for years), families, not singles.
• Data sharing: Large scale. There is still good will, and energy towards this. .
• What is going well?
• Case Conferencing:
• Referrals for chronic problematic because Can’t find people - 80% cleaned up
• Main assessment center - isn’t doing the work with clients to document where they are
• More street outreach workers than ever before – regional outreach cooperative
• Assessment center doesn’t have best reputation - similar to COTs in burlington, VT (meg will look into what they did to engage this provider)
• Don’t have direct access to HMIS to fax SPDATs to then be manually entered by coalition
• Doc is supportive but not Lead on homelessness side. Jaime will reach out to the Doc to see about building will, will let Wendy know

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[January] Notes

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• CHNA coming up. Surveys going on and FGs coming up. Summit-Jaime will join the summit
• Noting the homelessness population is aging
• Skilled nursing facilities don’t take homeless because they can’t pay
• When is a delay a “no” ?
• Tried respite care with this provider and it’s just not going to work - want help with this
• Data sharing
• Oath of confidentiality
• ROIs personally between them and the client
• Depends on each agency
• Manager of case management social workers — sits in on these meetings (angela from CHI, ER docs and case manager director as backup from Erlanger (?)) -
• Memorial doesn’t share information
• Erlanger (?) shares more info
• Would love to move to a centrally shared data set
• Client would give permission to opt into entire system so wouldn’t have to be grassroots

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[January] Next Steps

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• Next Milestones/Next Steps
• Jaime work with Wendy to engage the doctor at the Assessment Center to build will
• CS reach out to coaching (Dawn) about how burlington engaged COTs
• Stakeholder mapping exercise over the next few months or a portion on a monthly coaching call
• Real estate / case manager / housing guru – BFZ provide something on this front
• Job description
• Principle underpinnings
• NEED PSH (one bedrooms are hard to come by)
• Fastest housing we can do takes 3 months
• Tried shared housing
• Agencies backing out of COC because they don’t have housing
• Amending funds with HUD
• Unique situation with Chattanooga - lowest median income, but all of a sudden expensive housing
• Portland or denver, foreign investors buying neighborhoods
• Palette housing just got approved

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February Agenda

• Welcome
• Pilot Updates / Urgent Items
• Project Progress
• Updates since our last call
• What is going well?
• Where are we stuck?
• Where are we trying to go next?
• Next Milestones/Next Steps
• Feedback

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[February] Notes

• Pilot Updates / Urgent Items
• Workshop–using an example from chattanooga? Yes, the Chattanooga team is on board. Jamie, Wendy, and Betsy will be on.
• Project Progress
• Updates since our last call
• Covid surge delayed progress.
• However now getting back in track after covid surge and other setbacks (arson at Catholic Charities and Homeless Healthcare Clinic dealing with surge)
• Covid surge shined a light on the deep need to have safe respite for people experiencing homelessness
• Officially starting process for keeping an eye on all of the camps not just individuals who present in ER. Making sure they are aware of what is happening and linking people needing medical attention to space
• Respite care feels like a gap–e.g. Person who has been to ER 4 times for same wound being infected. Respite care would not only help health but also provide time to support PSH
• Trying to get contact information (as much as possible) while in ER so that they can stay in touch
• Healthcare sometimes so busy they don’t have time to inform HRS and people experiencing homelessness leave before being contacted.
• How to engage people who do not go to ER (noticed that white people present in ER more frequently than POC, so street outreach linked to RN role is critical to approaching work equitably).
• Figured out how to do a completely different assessment that is capturing needs vs. access to care.
• Jamie v. skilled at looking at data and translating findings into actions to engage people
• New EHR update–first set of new questions are SDOH. Exciting step in moving forward toward shared data.
• CHNA summit–dynamic conversation, findings forthcoming (reviewers–”Chattanooga is on the verge of something big). ACTION: Share CHNA summit findings at next coaching call
• What is going well?
• (above) + Covid numbers going down after big surge
• Working to get rid of SPIDAT–have good examples of what a new assessment could look like. Going to present to coordinated entry committee (merged with equity committee)
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[February] Next Steps

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• Went well continued
• Working/learning with other communities that have transitioned from SPIDAT assessment
• Where are we stuck?
• Getting actual respite care up and running due to circumstances out of control (arson, covid surge, etc.) Hopefully they can break through this log jam
• Support? Healthcare perspective–covid has had a dramatic impact on financials. However, this work continues to be a top priority with the administration.
• Highlighting importance of relationships even during difficult times in the project–so things become a pause not a stop
• Access to available housing/shelter is a huge barrier right now. Relationships are great but can only get so far if there isn’t a place to send people. Some in healthcare side all it takes is relationships/communication but there is only so far folks can get without housing placements.
• Action Item: Anna B. to connect team to Community Solutions’ real estate team to see if they can support.
• Everyone looking for the magic button. Need some sort of centralized way to support options (e.g. a 1-800 number, but would need to be staffed by the right people)
• Action item: Nicole to share an example of what a written workflow could look like.
• Where are we trying to go next?
• Action item: BY next month, hoping respite care team can start meeting again on a monthly basis
• Can share learnings from RN who is part of street outreach.--learning questions?
• Position currently slated to end in June due to funding. How can we make the case to continue
• Quantifying cost, who could help share costs, etc.
• What is she seeing as the greatest need? Triage means something different in clinical care vs. in the field.
• One PSH program lost quite a bit of money, but the other gave back a lot of ##. Slots just aren’t available right now. Convinced one rapid rehousing program to take people up to a certain vulnerability score.
• Asking–is vulnerability high because of things that could be solved in the near future? It can be a risk to just house without support.
• Local landlords who previously would engage with CoC re: housing placements now have sold to out of state developers.
• Next Milestones/Next Steps
• Feedback
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[February] Next Steps

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• More people moving to Chattanooga, dramatically impacting available affordable housing
• Trying to engage landlords, but generally aren't engaging.
• Ideas–Flex pool (guide recently released). They use their administrative to put up a shield so landlords don’t need to engage in the regulations. Also helps to address stigma from certain types of vouchers.
• Try not to use the word “homelessness” and rather other descriptors that people have less value judgement toward (e.g. housing for young people vs. housing for homeless youth)
• Mayor pulled together a racial equity committee and declared racism a public health crisis
• Data showed that housing costs went up at a higher rate in neighborhoods with a high population of PoC as compared to whiter neighborhoods.
• Can we advocate to get affordable housing on the cities racial equity platform (in addition to others?).
• ACTION ITEM: Jamie to share data from Mayor’s racial equity committee on housing costs.
• Next Milestones/Next Steps
• ACTION ITEM: Keep chipping away at this work with landlord engagement/access to permanent housing/using vouchers available.
• Tried shared housing. Works well in general but not a good fit for those who are medically fragile.
• Need service/supports in addition to housing, otherwise not sustainable. Seems even more true for community with high vulnerability.
• Feedback [what can IHI/CS bring to coaching calls going forward]
• Encouragement
• Ability to re-frame where we are.
• “Feels like we’ve been swimming for a long time in waves of covid. Now we need to come up from air and keep working on good

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[March] Agenda

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• Pilot Updates / Urgent Items
• Project Progress
• Updates since our last call
• What is going well?
• Where are we stuck?
• Where are we trying to go next?
• Next Milestones/Next Steps
• Feedback

[March] Notes

• Welcome
• Pilot Updates / Urgent Items
• Confirmation that pilot is extended for a third year – how does that change the process?
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• Project Progress
• Updates from Betsy
• Reinstate respite team – subgroup that was meeting (set a meeting date)
• Meetings set up with right groups, just need time to move it forward (respite)
• Welcome Home (hospice) - for individuals experiencing homelessness adding four to six respite beds (not for hospice) for individuals with cancer diagnosis
• Catholic Charities building (next to hospital) - looking at doing longer term patient placements going through different therapies (wound care, PT, etc) with home health care eligibility. 3 weeks to 6 month placements w/ case manager helping them move toward PSH.
• Community kitchen - Overnight care (not a shelter) for outpatients from HC clinic prepping for surgery or procedure or need to be off the streets (short term).
• Looking to share list of most frequent users (quietly, appropriately) as a grassroots data sharing system (with an eye toward more robust data sharing)
• New foundation opening that wants to move into data sharing for Chattanooga. Spoken to Paulo Bravo about setting it up to Connect Communities. (sideways help)

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[March] Notes

• Mayor has placed Homelessness and Faith Communities as a lead initiative locally
• Welcome Home expanded. Created binder “how to make sure respite care beds aren’t used as the answer to the lack of affordable housing” workflow. (Once folks are well enough they are transferred). Model could be used elsewhere as well. Informally been in place, so now formal adoption was created to eliminate bottleneck. Jamie to share out and scan over files.
• Jamie - seeing outreach from other agencies (bringing clients to case conferencing) but then not following up/updating.
• Betsy: Could be a timing issue on the hospital side where data is limited. Data sharing would open that door though.
• Wendy: Could that upload be done through HMIS?
• Jamie: They could upload their ADLs and medical certification faxed to AAAD. When homeless agencies are the ones falling through the cracks, it’s easier to correct since there is data access and shared data.
• AAAD receiving medical certification from hospital is fastest path forward (typically)
• What about a pre-designed form for each patient with check-boxes for forms required to be sent out (and where to send them).
• Discharge planning – when a patient hits their max # of days for reimbursal, past that, every day they aren’t discharged (because there’s no housing available) becomes pressing for hospital (costing $$)
• JA: Requests coming from healthcare to apply for insurance for patients (Georgia/TN Medicare/medicaid) (Special enrollment period for homeless individuals to qualify for TenCare or AAAD
• One fix would be a state/county social worker who facilitated that full time
• HS Finance Team often works on reimbursement for those situations
• Every month charity care committee reviews cases & costs going to collection
• Documents often live in multiple files/agencies/etc.
• For veteran housing – City of Chattanooga used HMIS (where files & forms were uploaded) but VA did not use HMIS, so Jamie sent directly to case manager at VA through email. (What about a similar role/process for HS/HRS?)
• FUSE: List of participants, Hospitals can say “yes we have seen them in the past x months” and then compare the list. Helps validate the list.
• JA: Haven’t been trying to get specific healthcare data but instead understand the process and improve discharge plans.
• What is going well?
• Where are we stuck?
• Where are we trying to go next?
• Next Milestones/Next Steps
• Feedback
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[March] Next Steps

• During last local call, spoke about severe lack of units for housing placements. Raised the question of: Should we add that to our list of goals? Is this a barrier to preventing our other goals?
• June: When Community health needs assessment is published and there’s movement around Mayor’s initiative for faith-based communities, we may have a clearer idea where we can fit/run alongside.
• Tips on how to keep people (PEH & Partners) engaged despite lack of housing
• CC: Celebrating successes can be really helpful & powerful. Share out at monthly meetings. Make a fuss about it!
• Individual stories are powerful. Everybody wants more of them but really share and celebrate those wins so far. Call out when partners had a particular role in getting something done.
• Other Group: Ran quick sharing out of data points where we can learn from partners and make it explicit that we’re relying on each other to get stuff done. Make a commitment at the end of each meeting for at least two partners to do something collaboratively.

Workshop#3 Team time: Day 1

Small group discussion

• What will it take to get case conferencing going? If you have already, what did it take?

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• How can you surface this kind of learning around a few people?

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• Who in your extended team do you need to share this method with?

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• What obstacles do you foresee in being able to learn from 1-5 people?

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Workshop # 3 Team time: Day 2

A Communications Framework

• Aim: What do you want to achieve?
• Audience: Who do you need to engage?
• Message: What do you need to say?
• Channels: How will you reach your audience?
• Story: How will you engage your audience?
• Review: What will you learn for next time?

Screening for homelessness earlier in someone’s stay in the hospital

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How do we convince other case managers to participate in case conferencing - scaling efforts

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Developing more housing

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Start Planning

• Who do you need to engage?
• Who can help? Who can stop you? Who will be neutral?
• What are the compelling stories to tell? Who should tell them?
• What are the different messages your different audiences need to hear?
• Who would be a good messenger?

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Take a few minutes to write down your answers to these questions:

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• Who do you need to engage?
• Who can help? Who can stop you? Who will be neutral?
• What are the compelling stories to tell? Who should tell them?
• Story of individual who was saved due to case conferencing - surgery would have led to death without a proper place to recover (a home)
• What are the different messages your different audiences need to hear?
• Screening for homelessness earlier in someone’s stay in the hospital - who holds responsibility to do this screening? And take into account in treatment plan
• How do we convince other case managers to participate in case conferencing - scaling this effort
• Developing more housing
• Who would be a good messenger?

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[April] Agenda

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• Transition Planning
• Pilot Updates / Urgent Items
• Project Progress
• Updates since our last call
• What is going well?
• Where are we stuck?
• Where are we trying to go next?
• Next Milestones/Next Steps
• Feedback

[April] Notes

Latest project:

• Staffing in place and beds coming online
• P&P, MOU Drafts in place
• Eligibility is still TBD – in process now.
• Case Conferencing is slowing down (one year in)
• Setting up processes for healthcare to use
• A few examples of how hospital can support HRS in placements
• No set process for hospitals to make referrals
• We haven’t ironed one out but that could be a next step that would help
• Jamie is focused on making processes for the HC to use
• Need for an in-between person that can create “linkage” and ask the right questions
• Can we look at examples of what went well and build from that?
• Current approach
• Documentation often falls to HRS
• What’s the ideal for HRS?
• Jamie: Liaison between HRS and HS
• Phone calls haven’t worked in reliable manner
• Sometimes capacity issues cause a problem

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[April] Notes

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Cont.

• Jamie’s former role would be useful in this same way to add capacity,
• Anna to raise to Pilot Team
• Betsy: Recommend embedding that person on the HRS side because they could flow between hospital systems instead of connected to just one.
• PIT Count Numbers doubled since last year
• Chronic case conferencing individuals (assuming disability) cannot utilize shelter because of stairs/set up. Not a true low barrier emergency shelter (50 beds for 1000 people).
• PLEH part of Chattanooga conference happening this week
• “Meaningful” engagement
• Jamie’s work
• Some to helpline, some to street outreach

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[May] Agenda

[May] Notes

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• Wendy will be leaving her current role by August
• ACTION: Faculty and Chattanooga team review the progress scale for June coaching call and identify current state/develop a coaching plan to keep forward momentum. Also consider plotting requirements on impact/effort grid.
• ACTION: IHI will send the Progress scale link to Chattanooga team as well as the recording of the March workshop.
• ACTION: Nicole will share job description for hospital liaison & healthcare coordinator positions
• ACTION: Wendy will loop her teammate into this meeting to ensure continuity. Anna can help onboard.
• TA needs:
• How to move from anecdotes of improvement to more formal measurement of project-level improvement
• Marketing pilot efforts/building public will (will send March workshop recording)
• Need for liaison of sort between homelessness response system & health system. Perhaps looking for funding to support this role? Ideally someone who isn’t tied to one hospital but rather could work among all three. Similar to what Jamie does among agencies in homeless response system. Perhaps housed in city or county?
• Project updates
• Respite–continuing to move this forward. One of three providing points has opened (Welcome Home–cancer-focused respite care)
• Data-sharing. City continuing to move this forward. Journey Foundation recently opened up as a result of a sale of NFP hospice. $100M to be used for local projects that would bring about systemic change. Looking into data-sharing. Team advocating for this with a focus on it being community-wide
• Case conferencing. Ongoing but need to confirm coverage for when Jamie is out on leave. Anna is happy to onboard anyone new to the Pilot work.

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[June/July] Agenda

Chattanooga: Aim Statement

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[June/July] Notes

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• Anna from Community Solutions has left; Ben will be stepping on as main coach from Community Solutions
• Sherry will be stepping in on these calls:
• With Welcome Home, social worker background, used to work in hospice
• The Org purchased 5 acres for a community of care
• The organization opened a cancer respite center to prevent deaths from treatable cancers
• From Betsy: When the homelessness side is at the table, it will be helpful to go through our hopes, plans, what we want to accomplish
• Care coordination - we are still working on this alongside the data sharing piece, including at the system level
• One challenge is that registration staff at CHI memorial are outsourced
• How would we know that we’ve captured everyone we need to capture in the system? How do we know we’re able to flag people for the homeless response system
• Nicole will touch base with the enterprise leaders around what the recommended coding/format/place to store the data and share with Betsy
• From Sherry - we’re looking at our board (mostly white men in their 50’s) and recognizing that it doesn’t match the population of people we serve
• Ben to forward along articles on the homelessness index and diversity
• It is unclear whether the case conferencing meetings have happened since Jamie has gone on maternity leave - issues around capacity and responsibilities with current process
• Nicole will followup with info about the FUSE outcome data collection

[June/July] Notes

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• Respite care work is moving forward with the three partners; meet monthly to talk about triage and medical support, how to get continuous grants to make it sustainable
• At Welcome Home, they have placed 1, 3 have died, and there are challenges with the others that we are learning about (fighting, some threats) - how do we set expectations with people before they move in. we’re hoping to get the word out sooner; the three that died may have been appropriate for hospice and chose to fight it.

[August] Agenda

[August] Notes

• SNOFO - Pursuing unsheltered and rural components
• Jamie - Possible to get Betsy and Sherry involved in the application in some way?
• Betsy - Happy to come alongside but it’ll take guidance from HRS to know where to help.
• Open office hours available for any potential applicant (Sherry may join)
• Medical Respite
• Community Kitchen is ready to go. Needs to hire a few folks to be overnight
• 10 hospital-like rooms
• Sherry is up and running
• 3 Bedroom cancer respite room in June (Sherry), 3 more by November/December
• HomePlace (Catholic Charities) will have two rooms with two beds each by EOY (hopefully)
• Avoid adding additional projects
• Care Coordination Project
• Case Conferencing stopped when Jamie went out on leave.
• Not happening right now – no outreach for Case Conferencing
• Outreach workers would provide pathway to housing
• Need Coordinated Entry Support (position was eliminated and has stopped all case conferencing) Similar to what Jamie was doing before.

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[August] Notes

• Hospital does not have the capacity to dedicate a person to fulfill this role,
• Could someone in CHI’s case management office to shadow and learn from this case conferencing?
• This role could support broader understandings of what it is like to work with individuals experiencing homelessness
• Betsy: Program for patients struggling with substance abuse where outside agency comes in to provide supportive care before discharge.
• Could somebody be on call from HRS serve in a similar capacity
• Data Sharing
• Need the capacity to install case conferencing to make this worthwhile
• Community will is there
• Sherry: How long is too long?
• FUSE was the original instance but they need better data matching
• FUSE is ramping back up – but need a better process
• Public Will
• Working on a campaign about how to get the stories out
• Messaging doc (Nicole Wilson) being provided for marketing team

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[August] Notes

• Respite care
• Moving forward (notes earlier)

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[October] Agenda

[October] Notes

• CS has given the homeless coalition funds for a project manager
• Mike and Betsy to sit down to talk through the job description and highlight the pieces Betsy would suggest are the most important for the interview process
• Mike can still share resumes
• From Betsy: ideas are easy to come up with but implementation takes so long - an perspective

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• This project manager would be involved with case conferencing and data sharing, organizing key partners, work on integrating the two systems of care (homelessness system and medical system)
• Would be helpful for them to also document what the existing resources in the system are and hand that out to different parts of the system
• Nicole to also resend liaison job description and learnings
• Mike to send Betsy and Sherry the job description; would be helpful to have buy-in and input from the Erlanger system if Mike could send there as well. Not sure who from the Parkridge system - Dr. Menderadi might have more luck reaching out to them.

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Laura to resend the original prospectus for the pilot out with notes

[October] Notes

• BNL includes: Name, age, questionnaire on whether they want a roommate, the organization that’s working with them at the time
• Do we want to include Dr. Menderati in one of these meetings, to talk about who from Erlinger has access to the HMIS?

[November] Agenda

November - Notes

• Hotel Eviction/Shelter closed at last minute, 339 individuals (Week before Thanksgiving)
• Chris to meet with Ben, Meg & Catherine C on Tuesday – then more One on Ones
• Case conferencing – to touch base with Mike about where that stands on project list
• Discharge:
• A clear desire to build out better processes but still need SDOH tool to identify those in need on the Hospital side
• Time to build out conversations around who and how to identify individuals at risk of homelessness in a trauma-informed way – but need resources and education materials to make this happen.
• A big gap to close for the system but a good area to focus in 2023
• Before the end of the year:
• Respite plan budget is set
• Needs:
• MOU for case conferencing
• Permissions
• Catherine to ask Lauran H for them and share

Chattanooga: August 2022 (last updated July, 2022)

Scorecard Notes - 1/18/23 (Outreach & Inreach)

Scorecard Notes - 1/18/23 (Participation from SPs & BNL)

Scorecard Notes - 1/18/23 (Policies and Procedures)

Scorecard Notes - 1/18/23 (Data Infrastructure)

Scorecard Notes - 1/18/23 (Data Infrastructure)

[February] Agenda

February - Notes

• Chris back in March
• Some small workgroups through Advisory Board about specific sub-populations of focus
• Tentative: PIT is down from last year
• Hamilton County is done, rural counties tbd
• Almost 40% in unsheltered count
• Seems to align with coalition’s perspective but tbd
• 563 unsheltered (1008 last year), 785 total = Hamilton County
• Need to huddle with Nymark about respite beds
• Mental and behavioral health is a major challenge
• Need to launch and then see what’s working
• Cherokee Mental Health has been a partner for Sherry
• Trauma informed training could be set up for the group?
• What would be on your dream list for possible Journey Health Foundation investments?
• Affordable housing. PSH.
• Affordable behavioral health (not insurance dependent, No expansion in Medicaid)
• Data sharing / exchange (neutral)
• Flexible funding or subsidy pool
• Coalition has one but it’s for literal homelessness but there is some diversion and prevention $ too
• Food dessert mitigation
• Banking/alternatives to payday lenders
• Welcome Home has DEI grant from Community Foundation to diversity their hospice and respite programming

Measurement: Project Level

By-Name List Re-Launch

Medical Case Conferencing

Discharge & Respite Care

Scorecard evaluation on coverage, infrastructure, and policy %

Data Reliability Score/%

# of respite care bed days occupied /

# respite care bed days available

# people discharged to housing

# clients new this month who had case conferencing within X days of their intake

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# clients new this month

# primary, outpatient or community-based care visits by people served by case conferencing

Utilization via Inpatient days

Equitable access or outcomes of Respite Care

[March] Agenda

March - Notes

• Case Conferencing set to launch in April
• Need to figure out how to share BNL With CHIS
• Place value assessments – need to compare to others that have used the VISPIDAT intake
• How can CHI cross-reference a list if they don’t have HMIS access?
• Every two weeks
• Reached out to CHI Memorial
• Will reach out to
• Will include LHD’s Healthcare for the Homeless too
• How to prioritize and set the initial conferencing list?
• # of visits (high priority for health system)
• Difficult to discharge (no safe discharge)
• High utilization
• High ER Utilization may look different
• Chronic SUD (typically alcohol)
• How do you make it so the healthcare staff say “hey this is a big help for us.” when they go to case conferencing.
• Start with outpatient clinic – some follow up needed.

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Next steps:

• Aim for late April 3-5 person case conferencing as test/run through of integrations
• HMIS Group – Figure out how to get correct, quality data on BNL for chronic
• Distribution – How will we share the actual data with the health systems in a secure way?
• Healthcare - How will we use this data within our own system?

[April] Agenda

April - Notes

Case Conferencing:

• Discussion about how to build out list and prioritize list for case conferencing.
• Each system to identify potential clients from BNL
• Hospital needs a process to identity who is “chronically” homeless - Cat will share from another site
• Ben and Cat to attend on 5/3
• Erlanger and County homeless h/c will join

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Measures discussion:

• Potential measures - % of people placed in RCP or PSH, timely access to cc, intake in CES, impact on d/c from hospital (only if HRS goes into hospital)
• Important to report measures disaggregated for BIPOC

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Next steps:

Coaches need to help team to make a process flow to demonstrate the range of homelessness severity to support HS to make appropriate referrals

• Chris having a general meeting to reintroduce case conferencing on May 3
• Chris will have CE specialist Stephen mention “read-only” BNL and related protocols
• From that call, plan would be to set up a recurring call after that.
• Catherine to send out list of measures post-call
• Catherine to send out hospital process for identifying chronically homeless
• Ben following up on questions from Jodie re: BNL and inactive policy questions

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May - Notes

• Chronic Case Conferencing
• Thursday at 2pm - in person
• View only BNL Distributed to that group
• Lauran to send case conferencing agenda, organization or meeting, report and note template (complete)
• Jodie has been updating BFZ dashboard
• Integrating Healthcare into Case Conferencing (Angela’s absence)
• Betsy is not directly over the team that would name somebody to fill in for Angela
• Hospitals are very focused on just in time help & information - also pressured with throughput - moving clients to d/c
• Chris might do a lunch and learn for the CMs on 211/CES
• Could Chris consider a hospital liaison type role or rounding to build relationships at hospital?
• Currently 126 individuals on chronic BNL
• Grant fron NIMARC for Respite
• Target is 4 beds by end of June or early July
• Introduction to Journey Health (possible funders)
• Lauran to see if Journey Health might be able to join next coaching call in June

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[June] Agenda

June - Notes

Set up call next week for CHI - Case Management leadership and Chris to talk through how to get CHI to the case conferencing.

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Megan Williams:

• Memphis Director of Complex Care (population Health) Regional One Health
• https://www.mass.gov/doc/accs-self-sufficiency-matrix-0/download

July 2023 - Agenda

[5 minutes] Welcome & Community Updates

[20 minutes] Measures for Case Conferencing (Chronic) aka What are you learning?

[15 minutes] Debrief of CHI conversation & talk through next steps

[5-10 minutes] Sustainability & last few months of the pilot focus

July - Notes

• Chronic Case Conferencing: So far able to house two individuals
• Challenges regarding movement.
• Looking for ways to measure progress and learn/have conversations with orgs that join.
• 238 names on chronic BNL
• 27 on the veterans BNL
• CHI meeting
• Still challenges in getting CHI’s case management staff to the table due to capacity constraints but Chris will continue to engage.
• Erlanger capacity issues too but they’re involved.
• Lauran to make intro to Journey Health staff

Process measures

Outcome Measures

August - Notes

• Three Respite Care possible sites
• Working on funding and what it would take to transform (fire marshal, etc)
• Located three places for Respite Care
• One across from street from hospital
• One was already providing respite care for oncology patients who are experiencing homelessness
• Third respite (need name and types of beds)
• Welcome Home the only one up and running
• Applied for grants from CHI Health (CHI parent company)
• Community Kitchen, start with clients from homeless health care clinic to do a small pilot in Mid-Sept
• Rooms look similar to hospital rooms
• Need to hire some staff
• Two people who will cover for 24 hours, providing activities during the day, partoling during the night, and housekeeping
• Still working on triage
• Received funding $?

- Catholic Charities looking to use funding for behavioral health

-2 rooms 4 beds? (verify number of rooms and beds)

-Lose funding when using beds as respite

- How to support after converting beds into respite

- 30k received in funding NIMRC (verify funder)

- Added medical respite in Knoxville , have provided guidance on what works and don’t work

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August Notes

• Case conferencing
• Focus on individuals with referrals to rapid supportive housing and CoC
• Chronic homelessness
• Assistance given moving forward to make it sustainable and not relay on an individual
• Building a sustainability plan
• Doing the best with what he (Chris) has
• (Chris) Will like to co-facilitate with someone or an organization who can take over
• Dr. Moyer from healthcare provides the review
• Assigning roles and recognizing natural leaders
• Have individuals take roles for housekeeping (scheduling, taking notes, etc) who are apart of case conferencing
• Trying to figure out how to navigate between two systems
• Journey Health for funding to support case conferencing
• Clarity around the goals and purpose of the meeting
• To get people into permanent supportive housing
• Erlanger providing information in the case conferencing meetings on those who need medical needs
• First half of last meeting lack engagement and second half meeting become more engaged
• Facilitating for a hybrid meeting; making sure speaker is place in proper place and consider having pausing to encourage engagement and allow those virtually to feel apart of the meeting
• Have standing agenda items
• Space is not setup for hybrid meetings
• Needs to be able to identify individuals who has medical needs
• BNL is the only communication right now

- Veterans Case Conferencing

- Team is coming together

- This Thursday 8/31/23

- Easier to navigate due to the tenure/experience of the team compare to chronic case conferencing

September Agenda

• Case conferencing
• Bringing in data - connection to a person from one system to the other (# people newly connected)
• Debrief learning session - work plan, how this work fits into that
• How is race equity showing up in their work? Is there a story that they can highlight of equitable outcomes

September Notes

• Updates:
• Recuperative Care/Medical Respite
• Chattanooga Free Press is interested in writing an article about recuperative
• 10 beds starting September 1
• Betsy gets to answer ‘why the hospital is involved’ and highlight their work
• Catholic Charities will open 4 respite beds in January
• Lots of interest from the hospital side (seems like clinical ppl/social workers are interested in having people discharged here)
• Chattanooga Housing Authority is also involved
• Trial period where clients in homeless/HC clinic would use Chat Foundations Rooms to do an early test on how these beds will work
• Who’s eligible? For now it’s…
• Outpatient people who are appropriate for this type of care in an effort to avoid a hospital stay
• People who are discharged from hospital and eligible for home health
• Interest in partnering with Cherokee Health to include primary care, behavioral health and other medical support so that they can provide services for the Catholic Charities beds
• Working with NIMARC to define operational terms for eligibility (for example, eligible for ambulatory care)
• Clinic has looked at who will be referred from outpatient side to understand the impact this intervention, where they are getting daily home health care, would have on their physical well being, other outcomes, etc.
• There is anecdotal data that indicates most complex cases have a behavioral health component, so Catholic Charities is wise to bring in services that can meet those needs via Cherokee Health
• Length of Stay for these respites
• Community Kitchen is 2-6 weeks
• Catholic Charities is comfortable with longer stays, up to 2 months
• Welcome Home (Oncology Respite/Palliative Care/Hospice) will be longer (6mos +)

September Notes

• Sustainability for Respite/Recuperative:
• Partnering with NIMARC has been a game changer in sustaining funding
• Hypothesis that if there are early indicators of positive outcomes, hospitals might contract beds
• Currently there’s enough funding to run this for a year, and “then we’ll see”
• Lauran notes that CMCS is looking to build respite and recuperative care into the Medicaid benefit (!!)
• Learning Session Takeaways
• Appreciated opportunity to dialogue with other communities that are part of the pilot
• And connect with communities where Chris previously lived! Cool connection
• Question on data quality
• Chat is submitting and was curious what steps are left?
• A few items on the scorecard, and CS can bring in support around that
• Chat has changed assessment and their HMIS vendor (this is all in place now)
• Next Step:
• revisit the scorecard to see what’s left to check off or if everything is all set, Chattanooga can be confirmed for all singles data!
• Meg to find time for Jody, Chris and Stephen to meet with CS data team
• Making Shifts Happen
• Not yet eligible until quality data bc they have 6 points but need the quality data designation
• Additional Next Step:
• Meg to check that there is no overlap with Tennessee Valley CoC and CHattanooga CoC

September Notes

• Racial Equity
• No story yet from CHI
• From CoC perspective: Jody and Stephen, when developing formula for prioritization on BNL, take into account some of the underrepresented groups, or previously underrepresented groups and can get more information on that
• Question:
• How do we make sure that we’re including everyone that needs to be included?
• Growing Latino community in Chattanooga, specifically Guatemalan
• How are other communities ensuring that those that may not be documented are included
• This can be difficult to navigate
• Trust built in to disclose
• Ideas
• Connection to Fresno (doing this well) - are there healthcare partners involved there?
• How are we handling cases of intimate partner violence that also require a lot of sensitivity with data
• What stakeholders are already working with this community that have trust and can create these connections?
• What resources are available that do not require documentation, green card, citizenship, etc.
• Hamilton County School System is a resource! They have social workers and case managers to connect with for resource sharing or data sharing
• LaPaz is connected to YHDP group and youth case conferencing
• LaPaz is social service agency for Latino population
• Is Bridge (an agency) working with this population
• Working with churches that are focused on this population as they are the trusted entity, and you can bring resources to the church that could deliver as the trusted entity
• Betsy will ask if respite bed eligibility includes citizenship/documentation and if they are tracking citizenship

September Notes

• Discussion around who else should be on the coaching calls? Which partners are missing? Should VA/SSVF providers be here?
• Pilot Support
• Will continue in someway of building a network around communities thinking about the connection of health and homelessness

Scorecard Review - 10/5

• Notes

October Agenda

• Recent progress or a win
• Opened up beds at respite care - now working on referral criteria
• Working on funding for catholic charities to open up 4 beds
• Have funding from commonspirit national for respite
• 14 beds total
• Not including 25 beds from
• Next Steps on Scorecard
• Schedule time with CS in next couple of weeks to create work plan for remaining gaps
• Meg will schedule for late last week
• Domestic Violence Question
• Chris going to reach out with DV providers this afternoon
• Honora will connect with Gulf Coast team - Deena Whitman

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October Agenda

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• Support with telling their story of the pilot using template + timelines.
• What processes, ways of working have changed as a result of this pilot.
• Sustainability plan moving forward
• Plan for scheduled calls
• Coaching needs
• Getting clear on next goals/projects of focus for Chattanooga
• Case conferencing plus? (adding in healthcare partners?)
• Data Sharing? - enterprise level engagement at CommonSpirit
• Communication support requests

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Notes

• Recent progress or a win
• First 5 medical respite patients at the Homeless Healthcare Clinic - week 4
• Opened this up to hospitals for referrals and there are established pathways for this that went through field testing and they are going to write the criteria
• “Well on way” to getting funding for Catholic Charities to open 4 beds for a year!
• Funding comes from Nymark and Common Spirit National
• Next Steps on Scorecard
• Schedule time with CS in next couple of weeks to create work plan for remaining gaps
• Domestic Violence Question -
• Chris will try to reach out to DV providers in Chattanooga to start a conversation on how to include them in the By Name Data work
• Honora will call contact in Gulf Coast (Dina Whitman) to connect her with Chris
• Meg will schedule call for work planning the next few questions with JoAnna and Meg and Chris
• Data team is ready to confirm when Chattanooga is ready!

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Notes

• Support with telling their story of the pilot using template + timelines.
• What processes, ways of working have changed as a result of this pilot.
• Timeline is done - this is a start, scaffolding of mile markers
• Focus on November APSC and reporting out on your story of the pilot
• Next Step:
• Update acronyms
• Chris and Betsy to work on updates
• Betsy and Chris to send timeline to partners so they can fill in additional points as well
• Sustainability plan moving forward
• Plan for scheduled calls
• Chris would like to continue meeting and pulling in other key players
• Coaching needs
• Who do we reach out to? - Honora will be point person
• Getting clear on next goals/projects of focus for Chattanooga
• Case conferencing plus? (adding in healthcare partners?)
• Data Sharing? - enterprise level engagement at CommonSpirit
• Communication support requests

Notes

• Getting clear on next goals/projects of focus for Chattanooga
• Case conferencing plus? (adding in healthcare partners?)
• Data Sharing? - enterprise level engagement at CommonSpirit
• From Chris
• Will building with partners to heal mistrust within CoC as leadership changes
• Mistrust of BfZ/CS - functional zero hesitancy
• Veteran work is not just a ‘win’ and these are real people
• Built for Zero 101 - what the heck is this and why are we working with them?
• How do we heal? How do we trust? How do we collaborate?
• When working across sector - each agency, each sector has their own worldview, their own traumas, their own history and experiences
• How involved does one need to be to move it forward?
• Communication support requests
• Desire for Site Visit - request to send dates and desired outcomes to begin formal planning

Notes

• Sustainability and next steps
• Chris and Betsy explaining this work to community partners
• “Telling the story” and telling it as a unified front
• Chris has been able to speak with Betsy and Karen about how they can compare notes and identify high utilizers
• Chattanooga team is meeting with Washington County to discuss their progress with the data sharing
• Betsy is meeting with Ashley and Nicole collaboratively

November 2023 Sustaining your efforts beyond 2023

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Considerations for building the future state

Cross-sector team:

Who is involved now? Who is not yet involved? Consider refreshing your stakeholder analysis to identify needed partners and potential detractors.

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Portfolio of Projects:

Which projects are you continuing to work together on? What new projects are you outlining together for 2024 and beyond?

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Equity:

What have you learned about equity and disparity in health and housing outcomes? How have you worked to boost equitable outcomes? Who have you partnered with to do that?

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People with Lived Experience (PLE):

How have PLE been involved in your work in the pilot? How can PLE partner with you beyond this year?

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Data:

What data do you have about how people’s lives are better for your work? What stories do you have about working together differently? Do you have a North Star story that centers and motivates people’s efforts?

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Communications:

Who are the different audiences you are trying to reach? What stories of this work can you tell? How and where will you tell them?

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Funding:

For how long is your current portfolio funded? What funding opportunities are on the horizon? What projects could you engage in with future funding?

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November Agenda

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• Sustainability plan
• Support needed
• Betsy/CHI engagement from here?
• Status of their DSA? Individual ROIs (risk manager at hospital)
• Case conferencing - medical
• Celebration call prep

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November Notes & Next Steps