Model Proposals - Teen Living Programs Health Care for Homeless Youth Proposal Submitted to the VNA Foundation

The Teen Living Program (TLP) opened its doors in 1975 as a small, specialized house-care program for unplaceable older wards of the state. Over the years it has evolved into a multi-site agency providing an array of services to thousands of homeless children and young adults each year. The proposal from TLP does an excellent job of explaining the challenges that often prevent their target population from receiving adequate health services, and in turn, does an equally good job of explaining the impressive impact that its Nurse Practitioner has been able to achieve with the help of VNA funding.

This proposal for renewal funding was approved in full by the VNA Foundation Board at its August 1, 2002, board meeting. It is well written and clearly defines realistic outcome measures. We are pleased to offer it as the Proposal of the Quarter for the quarter ending September 30, 2002.

A. Agency Overview

Teen Living Programs has successfully served homeless and at-risk youth in Chicago for more than twenty-six years. Beginning as a specialized house care program for hard to place older wards of the state, TLP now provides an integrated network of emergency services and residential programs to homeless and runaway youth. The mission of Teen Living Programs is to create hope and opportunity for homeless and runaway youth by assisting them to permanently leave the streets, secure stable housing, and build self-sufficient, satisfying lives. Our mission is guided by the belief that all youth are entitled to a safe and loving home, where they gain an assurance of belonging, a desire for independence, a commitment to competence, and a heart of compassion.

Last Fiscal Year (FY 2001) TLP's programs and staff:
1) The Chicago Area Immunization Campaign works to raise immunization rates among children 0-2 years of age through public awareness and provider education. When this project started in 1991, children under the age of 3 in Chicago had a 35% immunization rate. Today over 70% of these children are immunized

• had 6,634 contacts with homeless youth on the street, providing them with information, referrals, and materials on food, shelter, clothing, and health services;
• engaged in in-depth encounters and street counseling with 430 street youth;
• served 1,279 meals at the Broadway Youth Center, the Agency's drop-in center for homeless youth;
• provided 125 minors a total of 766 nights of shelter and services;
• provided 126 young adults with a total of 3,876 nights of emergency shelter and services, and
• provided 29 young adults with 2,078 days of transitional housing and services.

Part II - The Need For Health Care Among Chicago's Homeless Youth
Virtually all of the homeless youth participating in TLP's programs lack health insurance or the financial resources to obtain health care. The majority of youth do not have a relationship with a primary health care provider, and many are unable to recall their last physical exam. The majority of youth present at least one specific, immediate health problem (infections, wounds, cuts and bruises, etc.) that has not been treated. When TLP's nurse practitioner provides medical attention for the immediate need, he often discovers that the youth also have additional health problems, such as sexually-transmitted diseases and poor hygiene and health habits that lead to ongoing medical concerns. Many of TLP's clients have a history of alcohol or substance abuse, become pregnant, and engage in other high-risk behaviors. Other youth suffer from undiagnosed psychological disorders such as depression, bipolar disorder, and eating disorders. From time to time, TLP also serves clients with serious long-term illnesses.

TLP's experience with the health needs of its clients is consistent with social science research confirming that homeless youth are at particularly high risk for developing conditions requiring health care, including sexually-transmitted diseases, malnutrition, allergies, ear, nose and throat problems, dermatological problems, gastrointestinal problems, infectious diseases, trauma, psychosocial problems and pregnancy.

(Farrow etal., Health Needs of Homeless and Runaway Youth, Journal of Adolescent Health, 13:717-726 (1992);
Monitoring the Health Status of Hard-to-Serve Children: Lessons for SCHIP Implementation, National Governors' Association, Health Policy Studies Division Issue Brief (1998); American Academy of Pediatrics, Health Needs of Homeless Children and Families, Pediatrics, vol. 98, no. 4 (Oct. 1996) Homeless youth also cite numerous barriers to care, such as lack of insurance, concerns about confidentiality and parental notification, confusion over the need for parental consent for treatment, fears and misconceptions regarding accessing health care, and long wait times for appointments at clinics. (Ibid) In general, youth are much more willing to seek out medical care from health care providers or clinics specifically focused upon the needs of adolescents. (Ibid)

Part III: Program Methodology -- Healthcare for Homeless Youth
Through Health Care for Homeless Youth, TLP provides direct primary health care and health education to homeless youth. The project also addresses the problems of lack of access to health care and homeless youth's unwillingness to take advantage of available health services.

With assistance from the VNA Foundation, TLP hired John McCue, ND, RN, FNP, to provide primary health care for TLP's residential and outreach clients over the age of eighteen, and minors on an emergency basis. The nurse practitioner treats immediate health needs as well as long-term health concerns. Having an on-staff nurse practitioner has significantly reduced the number of referrals to outside agencies, however, when referrals are necessary, the nurse practitioner takes responsibility for ensuring clients comply with the referral. In addition, the nurse practitioner provides critical health and nutrition education to both staff and clients, enhancing the long-term health and well being of TLP's clients.

TLP operates two separate clinics, one at Belfort House, TLP's residential facility in the Bronzeville neighborhood and one at the Broadway Youth Center, TLP's drop-in center in the Lakeview neighborhood. The nurse practitioner holds office hours by appointment for youth (approximately 6-10 hours per week) who reside at Belfort House and is on call for medical emergencies. The nurse practitioner also has regularly scheduled hours at the Broadway Youth Center five days per week, (approximately 30 hours per week) including two evenings when the clinic is open until 11:00 p.m. There, he provides treatment, education, and referral services to outreach clients through scheduled appointments and on a walk-in basis. Health care services are also available to the youth residing in TLP's new scattered-site transitional housing program. Scattered-site participants will be able to access health services at either Belfort House or the Broadway Youth Center, at their convenience. At both clinics, the nurse practitioner has dedicated office and lab space for managing the Health Care for Homeless Youth program and treating clients with appropriate privacy. Each office is outfitted with appropriate durable medical equipment, non-durable medical supplies, and medications appropriate to a community health setting.

Health Care for Homeless Youth does not duplicate any services that TLP's clients can reasonably access and are likely to access. TLP is one of only a handful of agencies in the City offering residential and emergency services geared specifically toward homeless and runaway youth. For example, TLP is aware of only approximately sixty emergency shelter beds in the City of Chicago designated for homeless youth. TLP provides twenty-four of those beds. Street outreach programs and day programming centers like TLP's, specifically targeted to homeless young people, are similarly limited. Second, as discussed above, available health clinics have proved insufficient to serve the needs of many homeless youth, especially in light of young people's resistance to following through on referrals and waiting for appointments.

Staffing and Implementation
As previously mentioned, TLP hired John McCue in June 2001 to develop, manage and administer Health Care for Homeless Youth. Mr. McCue received an ND (clinical doctorate) as a family nurse practitioner from Rush University and has extensive graduate program clinical and health education experience in community health settings.

The nurse practitioner's responsibilities include the following:

• Assessing the health care needs of all residential clients and all BYC clients who participate in TLP's intake and case management process;
• Providing primary health care to residential and Broadway Youth Center clients, including health exams, diagnosis, prescribing medicine as needed, TB, STD and HIV tests, testing follow-ups, vaccinations and prenatal care;
• Maintaining current linkages and establishing new linkages with outside health providers;
• Managing the ongoing health care needs of clients in the residential program, including clients with serious health issues;
• Transporting clients to health appointments and testing sites, as necessary;
• Coordinating appointments and follow-up visits with the collaborating psychiatrist;
• Conducting health education and nutrition training for staff and clients, and
• Participating as a key contributor in clinical case staffings
• The nurse practitioner has also recruited a collaborating physician, Dr. Garofalo from Howard Brown Health Center and Children's Memorial, who has entered into written collaborative agreement with TLP as required by Illinois law. See Nursing and Advanced Practice Nursing Act, 225 ILCS §65/15-15. Under this agreement, Dr. Garofalo participates in joint formulation of medical orders and guidelines with Mr. McCue in accordance with accepted standards of medical practice and advanced nursing practice; is on-site at least once a month to conduct chart reviews and provide medical direction and consultation; and is available for telephone consultations on medical problems, complications, emergencies and patient referrals.

Some of the health issues addressed by the nurse practitioner have included; chronic headaches, a sprained ankle, hematuria (blood in the urine), several cases of acute asthma, sore throats, influenza, 10-15 cases of pneumonia, two TB diagnoses, skin rashes, many upper respiratory infections, a skin wound that would not heal (client was diagnosed with cellulitus), stomach pains (client was diagnosed with peptic ulcer disease), genital warts (HPV), Gonorrhea, Chlamydia, and fungal infections. One youth was diagnosed and successfully treated for Pelvic Inflammatory Disease (PID).

The nurse practitioner has also diagnosed and provided referrals for treatment for two youth who tested positively for HIV. One youth is under the care of TLP's Collaborating Physician, Dr. Robert Garofalo, at Howard Brown Medical Center. The youth also continues to visit TLP's nurse practitioner at the Broadway Youth Center. So far his treatment has been successful in terms of his CD4 count and viral loads, which are both within normal limits. A specialist at Children's Memorial is also treating another youth for gastrointestinal problems.

At the Broadway Youth Center Clinic more than 85 clients (unduplicated) have made a total of 227 visits. The majority of the visits were to address a chief medical complaint and 21 comprehensive physicals, including a complete medical history, were performed. Additionally, 31 HIV tests, 25 STD tests, 19 TB tests, two pap smears, and four immunizations have been provided in the clinic. A total of 57.75 hours of individual and group health education sessions were also conducted.

At Belfort House, 26 unduplicated clients have made 61 visits. Like at the BYC, the majority of the visits were to address a chief medical complaint and 15 complete physicals were performed. Additionally, the nurse practitioner conducted 11 HIV tests, 10 STD tests, 16 TB tests, two pap smears, and three immunizations. The nurse practitioner has also provided a total of 24.25 hours of individual and group health education sessions to youth.

More than 36 referrals have been provided for outside services, with the majority for dental care. TLP's nurse practitioner has encountered significant difficulty obtaining dental care for homeless youth. Finding free dental care, especially for youth who require surgical procedures such as extractions, has been a challenge. TLP's nurse practitioner has arranged for a local dentist to offer services at a reduced price ($35 a visit which TLP pays for) for TLP clients. This dentist has treated two youth. After repeated attempts to schedule visits for clients at free dental providers, the nurse practitioner was able to make appointments for two youth at Cook County Fantus Dental for tooth extractions. One youth had a tooth extracted at Pacific Garden Mission where TLP's nurse practitioner volunteers on a regular basis.

Collaborations and Linkages With Other Health Providers
TLP maintains ongoing linkage agreements with more than 50 health and social service providers in the Chicago Area. The most significant health care collaborations are with Chicago Health Outreach, the Howard Brown Health Center/Children's Memorial and The Institute for Juvenile Research. By bringing health care on site TLP has eliminated many of the barriers youth previously experienced when they attempted to access health care services through outside providers.

As previously mentioned, TLP has entered into a collaborative practice agreement with Dr. Robert Garofalo, M.D., MPH. Dr. Garofalo is Attending Physician in Pediatrics at Children's Memorial Hospital and is on staff at Howard Brown Health Center. Dr. Garofalo is also an Assistant Professor of Pediatrics at Northwestern University Medical School, and was formerly on the faculty at Harvard Medical School. Dr. Garofalo is a board-certified specialist in adolescent medicine, and has had extensive experience in working with homeless and at-risk youth. For example, while at Harvard, Dr. Garofalo helped to develop a community medical clinic serving homeless and at-risk youth, which in his last year there had over 9,000 client visits. Dr. Garofalo is a graduate of Harvard University, New York University Medical School, and Duke University.

In March of this year, Tom Wright, M.D. began a mental health clinic to serve TLP Youth. Dr. Wright is Assistant Professor of Child and Adolescent Psychiatry at the University of Illinois at Chicago and is the Training Director at the Institute for Juvenile Research at UIC, one of the nation's foremost research and training institutions devoted to matters of child and adolescent health. Prior to joining UIC, Dr. Wright was Chief of Adolescent Psychiatry at Northwestern Memorial Hospital, and was on the faculty of the Department of Psychiatry at Northwestern University Medical School. Dr. Wright is a graduate of the UIC School of Medicine, and Illinois State University. Through this collaboration, TLP anticipates becoming an IJR-designated training and research site for an upcoming project. Selection as such a site would enhance TLP's mental health services by making the Agency a clinical rotation site for IJR interns, including psychiatric residents, clinical psychology graduate students and social work interns. Further, it would allow the Agency to participate with IJR to conduct much-needed research into the mental health and other clinical needs of homeless youth. Dr. Wright has already conducted 26 sessions with seven youth.

TLP has historically utilized the services of Chicago Health Outreach for youth who require specialized treatment for persistent health problems. For this project, CHO has loaned TLP medical supplies and medications, shared their technical expertise and agreed to perform laboratory work at no cost to TLP during the start-up phase of this project. TLP will continue to refer youth in need of more specialized health services to CHO.

The plight of America's uninsured has become an increasingly urgent issue as a result of the rising cost of health insurance and the economic downturn that has forced employers to cut back on health care subsidies to their employees. According to the U.S. Census Bureau, there were nearly 1.7 million Illinois residents without health insurance in 2001. A report released by The Urban Institute in August 2002 revealed that there were 192,960 children in Illinois who qualified for KidCare, but were not yet enrolled. The majority of these children and families reside in the Cook and collar Counties.

Studies have found that 7 out of 10 families eligible for KidCare do not know that they qualify. This presents a significant communications challenge to raise community awareness of the program, galvanize enrollment, publicize successes, and monitor the media to ensure that accurate information is reaching the public.

The uninsured are not a stagnant population, but a repeatedly changing one. Wage earners in low paying positions face unstable employment, frequent job changes, and the constant threat of losing employer based insurance if they are offered insurance at all. In fact, the New York Times recently reported that one of the fastest growing populations of uninsured is the middle class as a result of large number of layoffs in the technology and communications fields. It is for this reason that enrollment and outreach efforts for the KidCare program must continue to reach the growing uninsured population.

Program Description
Project Goal: To increase access to health care for underserved families in the Chicago area.

With the knowledge and experience from a similar project launched by Metropolitan Chicago Healthcare Council (MCHC), a committee of CKF-IL coalition members were brought together to discuss the institutionalization of KidCare and FamilyCare into the health providers setting. Through the support of the Michael Reese Health Trust, MCHC worked with five hospitals over the course of a year and enrolled 3,200 children and pregnant women into KidCare. Each hospital was given $35,000 to help cover staffing costs. Each KidCare application that was submitted and approved through the project generated on average $1,200 in revenue to the participating hospital in one year; this is payment for health care that would have otherwise gone uncompensated.

MCHC's project shows how the health care setting provides an opportunity to refer uninsured clients seeking health services to KidCare or FamilyCare and enroll them on-site. Families without health insurance often use emergency rooms for their source of primary care, which can lead to higher insurance rates for those with private or employer-based insurance, as well as increasing the financial burden on families already struggling financially. By identifying these self-pay clients, the Hospital-based KidCare Enrollment Project would be able to enroll eligible families on-site and promote preventive health services with an initial health screening by a nurse. As a result, clients would gain greater access to affordable options for comprehensive medical coverage. The VNA Foundation grant would allow CKF-IL to work with nine community hospitals and one FQHC to institutionalize KidCare into the hospital setting and provide access to preventative as well as emergency care.

Part IV - Goals and Objectives
The overall goal of Health Care for Homeless Youth is to improve the health of the homeless youth in TLP's programs, to teach them healthy living skills, and to encourage them to adopt healthy lifestyles. TLP expects to achieve the following specific goals and measurable objectives, identifying each object as ("P") process outcome or ("O") objective:

Goal No. 1:
Assure that all residential clients ages 18 and up in need of and desiring primary health care services, receive those services on-site.

• 75 residents will be offered comprehensive health assessments, including but not limited to a full physical exam, TB test, STD screening, and HIV test, within 72 hours of intake(P).
• 100% of residents needing and desiring primary health will receive these services on-site (O).
• 100% of residents in need of outside health referrals will be given a referral (P).
• 70% of residents receiving outside health referrals will follow through with the referral (O).
• 100% of residents in need of vaccinations will receive the appropriate vaccinations (O).

Goal No. 2:
Assure that Broadway Youth Center clients receive primary medical care.

• 125 drop-in clients at the Broadway Youth Center (BYC) will be offered a comprehensive health assessment, including but not limited to a full physical exam, TB test, STD screening, and HIV test, within 72 hours of contact for services.
• 100% of BYC Clients needing of and desiring primary health care will receive these services on site (O).
• 100% of BYC Clients in need of outside health referrals will be given a referral (P).
• 70% of BYC Clients receiving outside health referrals will comply with the referral (O).
• 100% of BYC Clients in need of vaccinations will receive the appropriate vaccinations (O).

Goal No. 3:
Educate staff on health and nutrition issues

• 24 hours of health education training, including general health, hygiene, nutrition, common diseases, and universal precautions, will be provided to TLP's direct care staff (P).
• 80% of TLP's direct care staff will attend scheduled trainings (P).
• Staff attending trainings will demonstrate a 20% increase in knowledge of covered training topics after each training program, based on pre- and post-test assessment (O).

Goal No. 4:
Educate clients on health and nutrition issues

• Fifty (50) hours of health education training (1 hour/week) will be provided to residential clients.
• 70% of residential clients will attend scheduled trainings (P).
• Clients attending training will demonstrate a 20% increase in knowledge of the covered training topics after each training session based on pre- and post-test assessment (O).
• Twelve (12 ) hours of health education training (1 hour/month) will be provided to BYC Clients.
• BYC Clients attending trainings will demonstrate a 20% increase in knowledge of the covered training topics after each training session, based on pre-and post-test assessment (O).

Part V - Tracking Progress Toward Reaching Objectives
Among the responsibilities of the nurse practitioner is to maintain records on treatment, referrals, education programs, and all other aspects of delivered services. TLP monitors the number of patients seen at the clinics, number of visits and follow-ups, identifies the incidence of particular medical concerns, symptoms, diagnoses, and outcomes. The nurse practitioner maintains a chart for each patient reflecting complaints, signs, symptoms, diagnosis, treatment plan and follow up. This information is entered into an Access Database while the Agency's Information Technology staff completes development of a more efficient tracking database.

To ensure that client feedback is obtained, the nurse practitioner is in the process of developing a client satisfaction survey to track patient response to the clinic's services. These responses will form the basis for future clinic services and enhancements. Youth also have the opportunity to voice their comments on services through a Youth Advisory Council at Belfort House. The Agency is also seeking to implement a similar forum for client feedback at the Broadway Youth Center.

The nurse practitioner compiles results -- both outcomes and client comments -- on an ongoing basis. The Director of Programs, together with the nurse practitioner, conducts quarterly reviews of the results as compared to the goals and objectives. TLP's Director of Programs will conduct a formal year-end evaluation of the program, including an evaluation of the results against the objectives as well as a discussion of program issues not reflected in the numbers. The evaluation results will be reported to the Executive Director and the Program Committee of the Board of Directors for review and analysis.

Part VI - Financial Request
Teen Living Programs respectfully requests renewed support in the form of a $75,490 grant from the VNA Foundation to support a portion of the Nurse Practitioner's salary and other operating costs associated with Health Care for Homeless Youth. This program seeks to improve access to primary health care for homeless youth, and provide health education to prevent serious illness and promote healthy lifestyles.

Budget Narrative for VNA Foundation Request

1. Current salary of Nurse Practitioner.
2. Benefits and taxes of $11,940 are based on the agency-wide benefit/tax package of approximately 20 percent.
3. Includes durable and non-durable goods necessary in the operation of the health clinics. Examples include gloves, syringes, and specimen tubes.
4. Medications are purchased to stock the clinic, and an account is maintained at a nearby pharmacy for youth to obtain prescriptions for drugs not available at the clinics.
5. Models, posters, and other materials to aid in the health education of the youth.
6. Reference texts for use by the Nurse Practitioner in providing care.
7. Continuing Medical Education required for certification.
8. Hardware repair and software enhancements/upgrades.
9. Standard office supplies and equipment necessary for the functioning of a medical office. Includes copier use, dedicated fax machine, and other office supplies.
10. For travel between the clinics, transportation of youth to referral sites, and travel to conferences and meetings.
11. Malpractice and liability insurance.

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