Shelter Provider Training:

Essentials of Care for People Who Have Been

Displaced

When the hurricane hits…

When the levees break…

When the bridge is out…

Bringing Health Care into the Shelter

Impact of homelessness on health

• Health conditions requiring regular, uninterrupted treatment—such as tuberculosis, HIV, addiction, and mental illness—are extremely difficult to manage without a stable residence.

• The Institute of Medicine has determined that individuals without a regular place to stay are far more likely than are those with stable housing to suffer from chronic medical conditions such as diabetes, cardiovascular disease, and asthma.

In other words…

• People in shelters are more likely to get sick.

• People in shelters have a tougher time getting well.

Medical insurance

• 71.3% of people experiencing homelessness have no medical insurance

- 21.5% Medicaid (Title XIX and S-CHIP)

- 3% Medicare- 4.1% private insurance/other

public insurance

Uniform Data System, BPHC, 2003

For many people…

The emergency room is the primary care provider.

Asthma

• A homeless child is three to six times more likely to have asthma than the average American child.

• Nationwide, 20 percent of homeless children have asthma compared to seven percent of all U.S. children.

Institute for Children and Poverty, 1999

Tuberculosis

• Although TB case rates have been decreasing since 1992, homeless people are still at an increased risk for contracting TB due to the crowdedness of shelters and the prevalence of health conditions that weaken their immune system. Centers for Disease Control and Prevention. Reported Tuberculosis in the United States, 1999, p. 2.

• Six percent of the 15,075 cases of TB in the United States in 2002 had been homeless in the previous 12 months. Centers for Disease Control and Prevention.Reported Tuberculosis in the United States, 2003.

HIV/AIDS

• Median prevalence rates of HIV that causes AIDS have been found to be at least three times higher in surveyed homeless populations (3.4%) than in the general population (less than 1%).

Lopez-Zetina J et al. Prevalence of HIV and hepatitis B and self-reported injection risk behavior during detention among street-recruited injection drug users in L.A. County, 1994-1996. Addiction, 96(4): 589–95, April 2001.

Common Concerns

• Respiratory Illness• Intestinal Problems• Infestation

Organizing Health Services in Shelters

• Provide a private, dedicated space for services

• Have a coordinator of health care & social services

• Conduct an intake interview with each individual or family

Organizing Health Services in Shelters (continued)

• Keep good records from the beginning

• Create a “communication notebook”

• Find, adapt, or create an up-to-date “resource notebook”

WASH HANDS.

No, really, get up right now and do it.

Just kidding.

Communicate. Communicate.Communicate.Communicate. Communicate.Communicate.Communicate. Communicate.Communicate.Communicate. Communicate.Communicate.

Preparing to Work in Shelters

• Review NHCHC manual, Red Cross shelter materials, and other resources

• Review common communicable diseases, common chronic health problems

Preparing to Work in Shelters (cont.)

• Prepare handouts for residents to prevent communicable diseases

• Contact resources (clinics, pharmacies, MDs) to determine who is available, when and how many patients they can see per day.

• Review CPR, first aid

WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.

Communicate.Communicate. Communicate.Communicate.Communicate. Communicate.Communicate.Communicate. Communicate.Communicate.Communicate. Communicate.

Daily Responsibilities in Shelters

• Make rounds to determine problems, issues

• Daily meeting of staff and residents• Set hours to see patients in the

nurses’ station• Update resource list• Follow up on pending items form

communication notebook• Have an experienced staff person or

volunteer to work with new people

WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.WASH YOUR HANDS.

Communicate.Communicate.Communicate. Communicate.Communicate.Communicate. Communicate.Communicate.Communicate. Communicate.Communicate.Communicate.

Some Reflections for Helpers

• The shelter is for basic needs to be met—food, safety, warm environment, comfort from the “storm”

• You do not have to be an expert in every aspect of care to be a helper

• It’s ok to ask for help from other staff and volunteers

Some Reflections for Helpers (continued)

• Share your ideas about how to make things better

• Get to know the shelter residents• The purpose of shelter services

is not as much “to give care” as it is to “work with” people to recover and return to normalcy as soon as possible

REMEMBER… We cannot solve all the residents’ problems. Many come with multiple issues that may not be related to the most recent disaster.

Environmental Healthand Safety

Basics of Environmental Health

• Wash hands—staff and residents• Control of infections, isolation,

prompt treatment as needed• Identify unsafe situations either

for transmission of disease or hazards

• Involve residents to help in identifying unsafe situations

Other Environmental Safety Issues

Creating a healthy environment is not just about infection control.

Be aware of…

• Family violence• Child abuse and neglect• Ways to prevent and de-

escalate potentially dangerous situations

Mental Illness and Substance Use Disorders

Adverse childhood experiences reported by homeless clients

• History of foster care, group home or other institutional setting - 27%

• History of childhood physical or sexual abuse - 25%

• History of childhood homelessness - 21%

• Ran away from home - 33%• Forced to leave home - 22%

Self-Report Data from the Interagency Council on the

Homeless, 1999.

Victimization and violence

• In a study of homeless and poor housed women, 67% reported severe physical violence by a childhood caretaker;

• 43% reported childhood sexual molestation;

• and 63% reported severe violence by a male partner.

Browne A and Bassuk SS. Intimate violence in the lives of homeless and poor housed women; Am J Orthopsychiatry 67(2): 261–278, 1997.

Mental health problems

• The experience of homelessness has been found to impair the psychological functioning of homeless people, regardless of age, gender, diagnosis, or medical/psychological history.

Gonzalez EA et al. Neuropsychological evaluation of higher functioning homeless persons: A comparison of an abbreviated test battery to the mini-mental state exam. Journal of Nervous and Mental Disease; 189(3): 176–181, 2001.

Severe mental illness

• It is estimated that 25 percent of homeless people have at some time experienced severe mental illness such as schizophrenia or a major mood disorder. P. Koegel, M.A. Burnam and J. Baumohl. The Causes of Homelessness. Phoenix: Oryx, 1996, p. 31.

Substance Use Disorders

• It is estimated that 20-35% of people experiencing homelessness suffer from substance use disorders.

Zerger, S. Substance Abuse Treatment: What Works for Homeless People?

Co-occurring disorders

• Some studies suggest that as many as half of homeless adults with severe mental illness also have a co-occurring substance use disorder.

D.L. Dennis, I.S. Levine and F.C. Osher. The Physical and Mental Health Status of Homeless Adults, a paper presented at the Fannie Mae Housing Conference, Washington, DC, 1991 p.9. As cited in Organizing Health Services for Homeless People. McMurray-Avila. M. 2001.

Taking Care: Coping with Grief and Loss

Common Causes of Stress in Helping Professions

• Too much to do, too little time to do it• Lack of job security• Relations with co-workers and

supervisors• Expectations of “how things should

be”• The risk of caring

Caring for your Self,your Soul, your Sanity

• Self-care (mind)• Healthy lifestyle

(body)• Spiritual care

(spirit)

How to stay healthy…

• Watch out for warning signs of stress and burnout

• Develop strategies for self-care on the job and off

• Take care of each other

Stress Test

You will be shown a photo with two identical images in it. Despite the fact the images are the same, people under stress tend to see differences between them. Look carefully at the photo. If you detect more than a few minor differences, you may need to take some time off.

Helping Others Cope with Grief and Loss

CHANGE=LOSS=GRIEF

GRIEF: The process of experiencing the psychological, sociological, physical and spiritual reactions to the PERCEPTION of loss.

Grief as Work

•Not commonly perceived that way

•Requires energy•Expectations make it worse•Must mourn all aspects of

losses•Can be complicated

Needs of Sufferers

•Compassion•Comfort•Sympathy •Freedom to be

angry•Listening•Friends and

Family

Communication and Connection

Motivational InterviewingMotivational Interviewing

“A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving

ambivalence”Miller & Rollnick, 2002

Also Known As…

“Helping people talk themselves into changing”

Elicitingvs.

Imparting

A Paradigm Shift

OARS: Basic Tools of OARS: Basic Tools of Motivational InterviewingMotivational Interviewing

• Open Questions

• Affirmations

• Reflective Listening

• Summaries

Motivational Interviewing is not a series of techniques for doing therapy but instead is a way of being with patients.

William Miller, Ph.D.

OARS: Open-ended Questions

•Can you tell me more about that?

• What have you noticed about your ____?

• What concerns you most?

• When would you be most likely to share needles with others?

• How would you like things to be different?

• What will you lose if you give up drinking?

• What have you tried before?

• What do you want to do next?

OARS: Affirmations

• Statements of recognition of client strengths

• Build confidence in ability to change

• Must be congruent and genuine

OARS: Reflective Listening

“Reflective listening is the key to this work. The best motivational advice we can give you is to listen carefully to your clients. They will tell you what has worked and what hasn't. What moved them forward and shifted them backward. Whenever you are in doubt about what to do, listen.”

Miller & Rollnick, 2002

“What people really need is a good listening to.”

Mary Lou Casey

Levels of Reflection

Simple – repeating, rephrasing; staying close to the content

Amplified – paraphrasing, double-sided reflection; testing the meaning/what’s going on below the surface

Feelings – emphasizing the emotional aspect of communication; deepest form

Reflective Listening Practice

1. Groups of three2. “Client” makes a statement (clear,

neutral, confused, psychotic, blaming, affirming, etc.)

3. Other two individuals taking turns practicing the three levels of reflection – simple, amplified, feeling level

4. Coach each other as needed5. Switch roles

OARS: Summarizing“Let me see if I understand thus far…”

• Special form of reflective listening

• Ensures clear communication

• Use at transitions in conversation

• Be concise

• Reflect ambivalence

• Accentuate “change talk”

Ambivalence “I want to, but I don’t want to”

• Natural phase in process of change

• Problems persist when people “get stuck” in ambivalence

• Normal aspect of human nature, not pathological

• Ambivalence is key issue to resolve for change to occur

Ambivalence

“People often get stuck, not because they fail to appreciate the down side of their situation, but because they

feel at least two ways about it.”

Miller & Rollnick, 2002

Understanding Ambivalence

Source: Miller and Rollnick (1991)

Costs of Status Quo

Benefits of Change

Costs of Change

Benefits of Status Quo

Cost-Benefit Balance

Exploring Ambivalence: Benefits and Costs

1. 4.

2. 3.

Status Quo Changing

Benefits

of

Cost

s of

Example

Helps me relaxEnjoy drinking with

friendsEases boredom

Feel better physicallyHave more $Less conflict with family, work

Hard on my healthSpending too much $Might lose my job

I’d miss getting highWhat to do about friendsHow to deal with stress

Drinking as before Abstaining

Benefits

C

ost s

Sustaining Community Dialogue and Response

Next Steps for Ongoing Training

• Commit to a culture of learning within your organization

• Plan at least one community-wide training in the next year

• Agree upon structures for sharing information between organizations

Next Steps for Community Dialogue

• Work to establish or enhance the use of community shelter standards

• Support the work of coalitions and other advocacy groups

• Hold regular networking meetings and events

Next Steps for Using the Shelter Health Guide

• Use the material to provide your own trainings for others in the community

• Use the Guide as part of orientation for staff and volunteers

• Use the information in the Tool Kits to educate shelter residents and staff

Thank you for being here today.