Permanent Supportive Housing Health Navigators

Grantee: Downtown Emergency Service Center
Timeframe: July 2018 – June 2021 | Total Amount: $510,000

Year 1: July 2018 – June 2019. Amount: $170,000
Year 2: July 2019 – June 2020. Amount: $170,000
Year 3: July 2020 – June 2021. Amount: $170,000

The goal of the Permanent Supportive Housing Health Navigators program is to provide individualized healthcare to medically compromised DESC clients in permanent supportive housing, who are unable to be served through existing healthcare resources. This remains the primary goal of the Health Navigators but methodology, data collection, staff trainings and reporting have changed significantly since the beginning of the Covid-19 pandemic.

In year three of the SHORE program, DESC is adapting how they deliver services within the context of COVID-19 pandemic response. DESC is taking a more conservative approach to Governor Inslee’s four phases of reopening because the client population is in a much higher risk category than the general population. Given this, DESC does not anticipate the ability to safely return to the group oriented, hands-on direct client services that they were providing pre-COVID. DESC has shifted away from an individualized approach to a population-based approach. DESC expects to operate under this approach through the new grant year; public health experts predict a second wave of COVID-19 outbreak that would likely coincide with flu season this fall.

When the project began in 2018, DESC understood that Washington’s Section 1115 Medicaid Transformation Project would allow DESC to provide direct healthcare supports in the permanent supportive housing environment. The Medicaid Transformation Project Foundational Community Supports (FCS) supported fee-for-service funding for two positions that worked alongside the Health Navigators. The original hope was that FCS funding would be able to continue support at the end of the grant period. Unfortunately, qualifying criteria for FCS is too narrow at this time, and DESC was unable to identify enough clients to qualify for funds to continue support of those two positions. Those positions were terminated at the end of 2019. DESC predicts this same issue if they moved to enroll and serve Health Navigator clients through FCS. DESC is advocating at the state level for changes to FCS that would allow for a greater breadth of qualifying factors, as well as services that are reimbursable.

In March 2020, DESC began meeting daily with their medical experts, and housing and shelter senior leadership to coordinate a response to COVID-19. During these meetings the following activities were accomplished:

• Created a system for contact tracing in their electronic health record.
• Performed contact tracing for COVID-19 positive clients.
• Coordinated cross agency nursing team outreach to clients flagged as having flu-like symptoms in their electronic health record.
• Coordinated a response to Public Health to facilitate involvement of their Strike Team when clusters of outbreaks were discovered through contact tracing efforts.
• Arranged for COVID site-based testing through local medical providers including Harborview and Neighborcare.
• Created a team that is dedicated to managing client referrals and discharges to and from Public Health run isolation and quarantine sites.
• Sourced PPE, thermometers and cleaning supplies.
• Changed internal processes for medication handoffs and meal delivery, taking these to individual apartments daily, along with flu symptom questions every 24 hours.
• Performed environmental assessments at 19 facilities, changing service delivery, physical set-up of office and client spaces, instituting handwashing stations at entries, and implementing staff symptom checks at each shift.

This approach allowed DESC to significantly limit transmission of the COVID-19 virus in both their permanent supportive housing and shelter settings, with just 29 clients contracting the virus as reported on June 1, 2020. SHORE played a pivotal role in this outcome by helping to shape agency pandemic response and providing the staffing to support ongoing contact tracing and care coordination efforts.

Because DESC’s services have significantly changed over the past few months, the Health Navigators outcomes data is also changing. DESC is now providing most client interaction through telehealth or other socially-distanced means and engaging with medical and program leadership on a near-daily basis. New metrics reflect best estimates for a resurgence of the virus in the Fall as has been predicted by multiple local and national health experts.

DESC continues to collect individualized client health data as possible, particularly related to the virus, but our administration of the Health Assessment Plan and Community Needs Assessment are limited primarily due to limitations of engaging with clients through telehealth methods.

The CNA, among other questions, also solicited information about clients’ self-reported improved feelings of health and increased control over their own healthcare. It proved too difficult for clients to understand these concepts as part of the HAP itself. In Year 3, Navigators will include these two questions as part of the CNA and will administer the survey twice per year to gather pre/post data to be used as comparison to measure individual clients’ thinking and behavior changes regarding their own engagement in healthcare decision-making.

Initially, Navigators worked with front-line staff who distributed client medications daily, usually at the front desk. This was measured by staff notes regarding who picked up their medication in a timely way. Now, the Kelly-Ross Pharmacy has created a portal through which our staff can access – with the client’s permission – data regarding current medications. Navigators are working with housing staff to learn how to effectively apply medication reconciliation information to helping clients with daily medication adherence and to reduce medication errors or duplication. Since external providers are also able to access the portal, it helps DESC staff be more accurate. DESC clients are often seen by multiple providers across different systems, so they are careful to ensure, to the best of their ability, that patients are not receiving inaccurate or out-of-date medications.