Care and housing for N.J.'s homeless a challenge

TRENTON Health care in New Jersey cities increasingly relies on coordinating care among various medical and social-service providers, but that model breaks down when it comes to one of the most vulnerable groups: the homeless.

They fall through the cracks for a variety of reasons. When they're on the street, they're almost impossible to find. They move from place to place when they do have somewhere to live. And in some cases, they're tossed out of housing or shelters because of inappropriate behavior.

What that means is housing agencies and health-care providers need to share information on an as-needed basis. It's a rarely realized goal.

The problems are particularly clear for officials of the three largest care-coordination agencies, in Newark, Trenton, and Camden. They described some of their challenges at a recent conference in Newark sponsored by PICO New Jersey, a nonprofit community organization supported by religious organizations.

It's important for housing and health-care officials to share data, said Ruth Perry, executive director of the Trenton Health Team. "We're performing case management for individuals who are homeless, and then housing professionals are also providing case management, but we're not really talking to one another at the level that we need."

Trenton's problems are particularly telling: In 2011, 300 homeless residents made 1,500 visits to hospital emergency departments there. Theoretically, that's what the Trenton Health Team was created to address.

The team's professionals coordinate care for people who rely on hospitals as their primary caregivers, scheduling follow-up visits with the appropriate doctors and clinics after release from the hospital.

But coordinating care relies on being able to reach patients when needed, which can be impossible with the homeless.

"We're talking about trying to make changes in ER utilization, but, more importantly, to get them the medical and social services and the mental health services that they deserve," Perry said. "We need our social-service agencies and we need the government and all that are involved to step up and join with us in a more robust way" to make that coordination possible.

Perry called on the health-care activists and community organizers attending the PICO conference to "stir the pot" with political leaders.

"We can really improve the system," Perry said. "Otherwise, we'll be limited in all that we do."

Perry cited the state's Homeless Management Information System, used by many counties to track where homeless residents are living (assuming they have a place), as well as what housing is available for them. Housing agencies keep the information confidential, but Perry said they should be able to share some of it with health-care providers.

"We need to liberate the data," she said.

Nadia Ali of the Camden Coalition of Health Care Providers, another agency that coordinates care, said its most successful attempt to provide frequent hospital users with housing was a program in which a nonprofit sponsored five housing vouchers.

"Outside of that, it's been an extreme challenge to get folks into housing," Ali said, noting that coalition staff had made many visits to help residents with the paperwork necessary to prove they're eligible for housing assistance.

"There's so much time that needs to be put into it," Ali said, adding that the homeless face many barriers, including a lack of knowledge about health-care and financial issues.

Pamela Robb of Camden called on health-care providers to make the case forcefully to city governments that health-care and housing needs should both be taken into account when cities are considering redevelopment projects.