King County 1200 King County

Courthouse

King
tQ
County Meeting Agenda
516 Third Avenue
Seattle, WA 98104

Board of Health
Metropolian King County Councilmembers: Julia Patterson, Chair;
Kathy Lambert, Vice Chair; Jan Drago
Alternate: Reagan Dunn

Seattle City Councilmembers: Sally Clark, Richard Conlin, Nick Licata

Alternate: Mike O'Brien

Suburban Elected Members: Ava Frisinger, David Hutchinson

Alternate: Dan Sherman

Health Professionals: Ben Danielson, MD, Frankie T. Manning, RN, M.A, Ray M. Nicola, MD, MHSA, FACPM

Staff: Maria Wood, Board Administrator (263-8791);

Director, Seattle-King County Department of Public Health: Dr. David Fleming

1 :30 PM Thursday, July 15, 2010 Room 1001

1. Call to Order

2. Roll Call

3. Announcement of Any Alternates ServinQ in Place of ReQular Members

4. Approval of Minutes of June 17, 2010

5. Public Comments

Briefings
6. 10-816 Tobacco Policy Progress Report from the SOH Tobacco Ad Hoc Committee

Scott Neal, Tobacco Prevention and Control Program Manager, Public Health - Seattle &

(15 7. 10-817
King County

2009 Health Care for the Homeless Network Annual Report

Natalie Lente, Healthcare for the Homeless Network Program Manager, Public Health _
Seattle & King County .
Maureen Brown, MD, Co-Chair, Health Care for the Homeless Network Planning Council
Greg Francis, Co-Chair, Health Care for the Homeless Network Planning Council
(', 10

King County Page 1 Printed on 7/6/2010 1

 Board of Health Meeting Agenda July 15,2010

8. Chair's Report

9. Board Member Updates

10. Administrator's Report

11. Other Business

12. Adjournment

If you have questions or need additional information about this agenda, please call 206-263-8791, or
write to Maria Wood, Board of Health Administrator via email at maria.woodcækingcounty.gov

King County Page 2 Printed on 7/6/2010 2

 ti
King Count
King County

Meeting Minutes
1200 King County
Courthouse
516 Third Avenue
Seatte, WA 98104

Board of Health
Metropolitan King County Councilmembers: Julia Patterson,
Chair;
Kathy Lambert, Vice Chair; Jan Drago
Alternate: Reagan Dunn

Seattle City Councilmembers: Sally Clark, Richard Conlin, Nick

Licata
Alternate: Mike O'Brien

Suburban Elected Members: Ava Frisinger, David Hutchinson

Alternate: Dan Sherman

Health Professionals: Ben Danielson, MD, Frankie T. Manning,

RN, M.A, Ray M. Nicola, MD, MHSA, FACPM

Staff: Maria Wood, Board Administrator (263-8791);

Director, Seattle-King County Department of Public Health: Dr.
David Fleming

1:30 PM Thursday, June 17, 2010 Room 1001

DRAFT MINUTES

1. Call to Order
This meeting was called to order at 1:36 p.m.

2. Roll Call
Present: 9 - Ms. Lambert, Ms. Patterson, Ms. Drago, Mr. Hutchinson, Ms. Frisinger, Dr.
Nicola, Mr. Licata, Mr. Conlin and Dr. Danielson
Excused: 1 - Ms. Clark

3. Announcement of Any Alternates ServinQ in Place of ReQular Members

Boardmember Sherman attended the meeting.

4. Approval of Minutes of May 20, 2010

Boardmember Hutchinson moved approval of the minutes of May 20, 2010 as presented.
The motion passed unanimously.

5. Public Comments
The following person spoke:

Dr. Victor Barry

King County Page 1

3
 Board of Health . Meeting Minutes June 17, 2010

6. Director's Report
Dr. David Fleming, Director, Seatte-King County Deparlment of Public Health, reporled
on a health care reform forum, sponsored by the Deparlment, that took place on June 16,
2010 and included Boardmembers Nicola and Clark on the panels. He also reporled
that requests for proposal for CPPW grants have been received and the process is
closed. The Deparlment received 77 proposals for healthy eating programs and 18
proposals for tobacco prevention programs. The grants wíl be made later this summer.

Briefings
7. 10-B15 Fall 2009 H1 N1 Response: Key Findings

Dr. Jeff Duchin, Chief, Communicable Disease Epidemiology and Immunization Section,
and Michael Loehr, Emergency Preparedness Program Manager, briefed the Board on
the H1 N1 flu outbreak and the responses to it.

Dr. Fleming answered questions of the Board.

8. Chair's Report
The Chair reporled on the Goat HíI Giving Garden, which county employees maintain
during lunch breaks and free time, to promote good health and cut the rising trend of
healthcare costs. The produce from the Garden wíl be donated to the Pike Place Senior
Center.

9. Board Member Updates

Boardmember Frisinger reporled that at the city of Issaquah staff meeting Seatte Tilth
made a presentation on community gardening.

10. Administrator's Report

Board Administrator Wood had no reporl.

11. Other Business

There was no other business to come before the Board.

12. Adiournment
The meeting was adjourned at 2:20 p.m.

Approved this day of

Clerk's Signature

King County Page 2

4
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King County
King County Board of Health
Staff Report

Agenda item No: 6 Date: July 1S, 2010

Briefing No: 10-B16 Prepared by: Scott Neal, Joy Hamilton

Subject: A briefing on the policy recommendations of the Board of Health Tobacco Policy
Committee.

Purpose: The purpose of this briefing is to report back to the Board on the work of the
Tobacco Policy Committee and to propose policy changes to the BOH code that would
decrease health inequities related to tobacco use and provide new opportunities to decrease
and prevent tobacco use in King County. Full code revision language and policy papers will
be prepared for the Board of Health meeting in September.

Summary: The Tobacco Policy Committee was convened to develop new tobacco policies
that respond to current opportunities and tobacco disparities in King County. The
Committee is recommending new policy to address smoking in public places/places of
employment, place restrictions on sale and availability of tobacco products, and to address
secondhand smoke exposure in multi-unit housing.

Background: In February 2010, the Tobacco Prevention Program at Public Health Seatte-
King County (PHSKC) made a presentation to the Board of Health on the threats and
opportunities related to tobacco use in King County. The presentation included current
tobacco use and mortality data, suggestions for policy responses to this data and new policy
options created by the Family Smoking Prevention and Tobacco Control Act. The Board
convened the Tobacco Policy Committee.

Committee membership includes BOH members Dr. Bud Nicola (chair), King County
Councilmember Jan Drago, Seattle City Councilmember Sally Clark and Lake Forest Park
Mayor David Hutchinson, and Gary Johnson, PHSKC Prevention Division Manager. This
report details the recommendations of the Committee to the Board of Health after two
working meetings.
Policy Recommendations: The Committee recommends three areas of policy action:
improving smoking ban in public places/places of employment, restricting sale and
availability of tobacco products and addressing secondhand smoke exposure in multi-unit
housing.

Smoking in Public PlaceS/Places of Employment (SOH Code 19.03)

BOH code 19.03 enacts locally the Washington State Smoking in Public Places law that
prohibits smoking in public places and places of employment. The BOH has the authority to
enact local regulations to implement this law, including defining terms that are part of the
state law. The following three revisions have been identified by the committee as necessary
improvements that would provide for more effective education and enforcement activities
that would achieve higher compliance.

1 5
 1. Clarify existinq KCBOH Code 19.03 by includinq definitions to kev terms such as
employee, private facility and enclosed area. The King County Prosecuting
Attorney's Office will provide guidance on reasonable and appropriate definitions.
Adding these definitions will provide for clear interpretation of KCBOH code _
improving the efficiency of education/enforcement efforts and creating a more
specific legal framework for appeal processes.
2. Adopt increased fines and escalating fines for large venues impacting siqnificantly
more people than typical establishments. Currently, all establishments, regardless of
size, face a $100 per day fine for violations of Code 19.03. This proposed action
would allow for larger fines at venues that impact a substantially greater number of
people and are often only in operation at limited times/days. Examples of these
establishments are stadiums, theaters, and other entertainment venues. These
establishments create health risks for a substantially greater number of people when
they fail to enforce Washington's prohibition of smoking in public places and places
of employment. Their event-limited hours allow only for occasional enforcement by
the health department, which often is not substantial enough to drive compliance.
larger fines for these establishments would reflect the larger risk and give PHSKC
effective enforcement options in cases of limited enforcement opportunity. The King
County Prosecuting Attorney's Office will help with gUidance on the appropriate level
of fines for these establishments.

3. Adopt re-inspection fees for establishments with multiple violations.

Enforcement of BOH Code 19.03 is complaint driven and education based.
Establishments initially receive a letter (notice of complaint) upon the first complaint
received by PHSKC. Subsequent complaints lead to onsite inspections and the first
violation observed during an inspection leads to an official warning and requires re-
inspection to verify compliance. A violation Portionof $95,320 inspection cost
observed in re-inspection (and all attributed to multiple inspections
subsequent violations) leads to a $100 fine.
While most establishments come into
compliance after one inspection, a small
number of establishments with repeated
violations generate over half of the total
cost of PHSKC enforcement related to
smoking in public places/workplaces
enforcement (see adjacent chart). Re- September 2007-
present
inspection fees are necessary to offset the
costs of multiple inspections for these repeat violators. Repeat violators cost more
because they require more Public Health staff time as well as assistance from legal
counseL. Importantly, escalating fines would also increase the incentive for
compliance for repeat violators that have not responded to repeat $100 fines.

Sale and Availabilty of Tobacco Products (SOH Code 19.04)

The following two proposed code enhancements restrict the sale and availability of tobacco
products by addressing products that target youth and by providing effective cessation
messages to people using tobacco at the point of sale.

1. Prohibit the sale of flavored alternative (non-ciqarette) tobacco products and

electronic cigarettes.
a. The Family Smoking Prevention and Tobacco Control Act of 2009 banned any
flavor but tobacco or menthol from cigarettes beginning in September 2009.

2 6
 New SOH policy can
apply similar
restrictions to all other
tobacco products
(cigars, cigarillos and
smokeless). This
complementary policy
is necessary since
youth in King County use alternative tobacco products more frequently than
cigarettes! and because tobacco products with candy flavors like grape and
mint hold high appeal for youth. Restricting these products to the flavor of
tobacco will reduce youth initiation of tobacco use by eliminating a line of
products designed to recruit youth by using packaging similar in coloring and
labeling to candy and by masking tobacco's flavor and harshness with candy
flavors. This policy would also limit the flavors of new future products like
Camel's flavored Orbs (similar to tic-tacs), Sticks (toothpick-like shape) and
Strips (similar to breath strips) that have candy-like flavors as part of their
appeaL. While the Board of Health has the authority to revise Code 19.04 to
include this restriction it is likely preempted by state law (RCW 70.155 -
Tobacco-access to minors) and may be challenged by the industry.
b. Results of a recent FDA analysis of two major electronic cigarette brands
found some of the same toxics and carcinogens as in traditional cigarettes.2
A ban on the sale of manufactured nicotine products not regulated by the FDA
protects King County residents from products like the e-cigarette, that are not
proven to be safe and in laboratory investigation contained harmful additives.
Electronic cigarettes, or e-cigarettes, are battery-powered devices that
vaporize nicotine, flavoring, and/or other chemicals into an inhalable vapor.
The product is marketed for a variety of uses including as a cessation aid and
as an alternative to tobacco in places where smoke is not permitted. None of
these uses have been approved by the FDA. There continues to be no
scientific support for the anecdotal claims that e-cigarettes are an effective
smoking cessation aid) There is concern that electronic cigarettes may
appeal to youth because of their high-tech design, easy availability online or
via mall kiosks, and the wide array of flavors of cartridges including chocolate
and mint.4 The FDA has classified the e-cigarettes it had examined as
combination drug-delivery products that require approval before being legally
sold in the US. Currently, the FDA's jurisdiction over these products is being
challenged in federal district court (Smoking Everywhere v. FDA No. 1:09-CV-
0077-RJL (D.D.C.). The Board of Health has authority to prohibit the sale of
electronic cigarettes and this action would be consistent with the FDA's
intentions.
2. Requiring point of sale signage that shows health risks of tobacco use and provides
Washinqton State Ouitline information. The health behaviors of people who use
tobacco are strongly influenced by their understanding of the health risks of
smoking. Those who perceive greater smoking-related health hazards are more
likely to consider quitting and to quit smoking successfully. Health warnings are
strongly associated with health knowledge.5 Research has shown that health
warnings which communicate the adverse health effects of tobacco use are among
the most effective at prompting smokers to quit.6 In addition, research has shown
that smokers find pictorial warnings more effective and engaging than text-only
warnings.? This policy would require both pictorial warnings and Quitline promotion

3 7
 at point of sale locations (see adjacent example from New
York City). This strategy also provides further outreach to
populations that may not be receiving Quitline messages
and sends the entire community the
in traditional ways

message that assistance to quit is available for everyone.

Research has shown that utilization of cessation services
increases when smokers are made aware of their
availability.8,9 Displaying this information where cigarettes
are sold will ensure that smokers are informed about
resources that are available to help them quit smoking,
and increase utilization of these resources to further
decrease smoking prevalence in King County. We will
look
to other cities that have enacted similar policies for
models when responding to legal challenges. At this time,
the committee is exploring this proposed intervention and, given more information
about the effect that this could have on business owners, this may be included in the
proposal for September's vote.

Addressing Secondhand Smoke Exposure in Multi-unit Housing

Develop model lanquage for landlords and/or cities, including smoke.;free policies and lease
disclosure policies. Secondhand smoke is a class-a carcinogen.1o Even small amounts of
secondhand smoke exposure have been shown to cause respiratory distress in people with
certain disabilities and pre-existing conditions including particularly children with pre-
existing health conditions such as asthma. Studies have shown that
cigarette smoke travels
throughout a multi-unit building and that structural modifications or air-filtration systems
are not adequate to prevent smoke from traveling between units.11 The Surgeon General
has stated that there is no safe level of exposure to secondhand smoke. Additionally, the
US Department of Housing and Urban Development strongly encourages Public Housing
Authorities to implement non-smoking policies in some or all of their public housing units.
Initiative-90l in Washington State effectively prohibited smoking in public places and
workplaces making the home the site of the largest exposure to secondhand smoke.
Multiple surveys have shown a very strong preference for smoke-free housing among all
residents in King County, regardless of age, race, gender, or socio-economic status. A 2008
PHSKC survey of multi-unit rental housing found that 1 in 5 residents report exposure to
drifting smoke at least a few times a week.12 There are large inequities in the proportion of
homes in which smoking is permitted: such homes are seven times more common among
low income groups than more affluent ones and twice as common among African Americans
and American Indians/Alaskan Natives than among whites.

Given that there is such high demand for smoke-free housing, it is not surprising that
apartment management companies and condo boards are showing interest in the idea and a
few key industry leaders have already made the decision to convert their units to a smoke-
free property. King County recognizes the current social climate as an important opportunity
to work with housing providers who serve residents who are disproportionally affected by
smoking and secondhand smoke exposure to assist them in making their properties smoke-
free and offering cessation resources to their residents who smoke. King County has
already successfully piloted the project with several housing providers. A barrier to the
further proliferation of smoke-free policies is the erroneous belief of many landlords that
such a policy is not legaL. The SOH, in developing model policy for landlords and cities, will
create change by being a leader in disseminating tools for desired and effective policy.

4 8
1 King County Healthy Youth Survey, 2004-2008.
2 Kuehn, B. M. (September 02, 2009). FDA: Electronic cigarettes may be risky. JAMA -
Journal of the American Medical Association, 302, 9.)
3 American Legacy Foundation: Electronic Cigarettes. Accessed at:
http://www .Iegacyforhealth .org/PDF/Electronic_Cigarettes(2) .pdf on 6/23/10.
4 FDA. FDA and public health experts warn about electronic cigarettes ¡press release). 2009
July 22, 2009 (cited 2009 August 12, 2009); Available from:
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm173222.htm .
5 Hammond D et al. (2006). Effectiveness of cigarette warning labels in informing smokers
about the risks of smoking: findings from the International Tobacco Control CITe) Four
Country Survey. Tob Ctrl15(Suppl 3): iii19- iii25.
6 Biener, L et al. (2000). Adults' response to Massachusetts anti-tobacco television
advertisements: impact of viewer and advertisement characteristics. Tobacco Control 9 (4):
401-407.
7 O'Hegart M et al. (2006). Reactions of young smokers to warning labels on cigarette
packages. Am J Prev Ned 30(6):467-73.
8 Farrelly, MC et al (2007). Effectiveness and cost effectiveness of television, radio and print
advertisements in promoting the New York smokers' quitline. Tob Control 16 (SuppI.1): i21-
i23.
9 Campbell SL et al (2008). Tobacco quitline use: enhancing benefit and increasing
abstinence. Am J Prev Med 35(4): 386-388.
10 United States Environmental Protection Agency. Respiratory Health Effects of Passive
Smokinq: Lung Cancer and Other Disorders. Washington: U.S. Environmental Protection
Agency, Office of Research and Development, Offce of Health and Environmental
Assessment, 1992 (accessed 2010 June 25).
11 American Society of Heating, Refrigerating and Air-Conditioning Engineers. Environmental
Tobacco Smoke: Position Document.) Atlanta: American Society of Heating, Refrigerating
and Air-Conditioning Engineers, 2005 (accessed 2010 June 25).
12 Gilmore Research Group. King County Survey of Rental Housing Residents: Compliance
with an Attitudes about Smoke-Free Rental Housing. King County, WA: August 2008.

5 9
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King County

King County Board of Health

Staff Report

Agenda item No: 7 Date: July 15, 2010

Briefing No: 10-B17 Prepared by: Natalie Lente

Subject
2009 Health Care for the Homeless Network Anual Report

Summary
Per resolution number 9-03.2 passed by the King County Board of
Health (BOH) in March 2009,
the BOH is the formal governance
board for the Public Health-Seattle & King County Health
Care for the Homeless grant under section 330(h) of the Public Health
Services Act. The
meeting proceedings ofthe BOH must reflect a review of
the Health Care for the Homeless
Network Anual Report each year.

Background
Oversight of the Health Care for the Homeless Network (HCHN) and consumer input required
by the federal grantor is provided by a community-based advisory Planning Council with
representation from throughout King County. The purpose of the Health Care for the Homeless
Network Planning Council is to provide programmatic guidance and policy direction to HCHN
administrative staff, Public Health-Seattle & King County management, and the King County
Board of Health. The HCHN Planng Council is not a governing body and operates in an
advisory function only.

In this role, the HCHN Planning Council is responsible for the presentation of
the HCHN Anual
Report to the BOH which provides an evaluation of
health center activities, including services
utilization patterns, productivity, patient satisfaction, achievement of project objectives, and
quality improvement.

In coordination with its i 5-member Planning Council, the Health Care for the Homeless
Network (HCHN) conducted a needs assessment in late 2008 to gather input from individuals
impacted by HCHN services, those not accessing services, and front line providers.

The results of the needs assessment led to the subsequent adoption of

the following HCHN
priority actions for 2009-2014:

i 10
 1. Ensure the application of evidence based practices that promote human dignity,
empower participants, and improve health outcomes.

2. Continue to provide services "where people are" including day centers, shelters, streets,
and supportive housing, working to improve access across all geographic areas of King
County where people ate experiencing homelessness.
3. Assure the provision of services that address the increasing acuity and complexity of
health care problems.

4. Address the need for increased access to information about health care resources and to
health care coverage.
5. Expand our awareness and focus on trauma informed care in recognition and response to
the high prevalence of cognitive and emotional impairments in the homeless population.
6. Continue to align investment strategies with those of the Ten- Year Plan to End
Homelessness in King County including alignment with the goal of the housing
first/supportive housing model to increase housing stability for persons with histories of
chronic homelessness.

The priority actions above guided much of the work of HCHN in the first year of the grant
project period and significantly contributed to the outcomes achieved by the program in 2009.

2009 Accomplishments

Enhanced Nursing Services in Supportive Housing

The Housing Health Outreach Team (HHOT) provided 912 nursing visits to 78 clients and linked
46 clients to primary care as a result of increased nursing services at Catholic Housing Services'
Wintonia building to support the growing number of Sobering Center frequent users placed in
the building. Neighborcare Health.

Established an Interdisciplinary Street Outreach Team

With funding support from the City of Seattle and United Way of King County, the new REACH
outreach team moved 36 clients, found living outdoors, to permanent or transitional housing.
Almost 1,200 service encounters were provided to 170 people in 2009. Neighborcare Health,
Evergreen Treatment Services and Pioneer Square Clinic

Expanded Case Management Services to Chemically Dependent Individuals

The REACH team enrolled 185 chemically dependent, chronically homeless clients into case
management, moved 95 clients into permanent housing and 53 into transitional housing, linked
93 people to inpatient CD treatment and helped 138 people access primary care. Evergreen
Treatment Services

2 11
 Increased Mental Health Outreach Services
Mental health providers served 435 people in Downtown Seattle, South King County and East
King County, funded through Mental Ilness and Drug Dependency (MIDD) sales tax revenue,
with an emphasis on people leaving jails and other institutions. Valley Cities Counseling and
Consultation and Harborview Medical Center/Pioneer Square Clinic

Coordinated Emergency Response for People Living Homeless

In response to the novel H1N1 influenza and the flood threats posed by Howard Hanson Dam,
HCHN developed a homeless response plan in preparation for both emergencies. HCHN
convened a stakeholder group of funders, governent and health care agencies, and advocates to
guide the planning process.

Implemented Two Federal AR Grants

Public Health received two federal grants to increase primary care and social work, support a site
renovation for an expansion of Medical Respite, create new exam rooms in a Public Health
Center, purchase medical and dental equipment, and help plan for electronic medical records in
Public Health.

In 2009 HCHN maintained a diverse funding base of approximately $6.4 million annually, with
support from:

Federal- HHSIHRSA/Bureau of Primary Health Care - Health Care for the Homeless
Program grant (Federally Qualified Health Center)
Federal- Housing and Urban Development, Supportive Housing Program (2 grants):
· Medical Respite -a 22-bed recuperation program for homeless adults
· Pathways Home -countywide medical case management for homeless families
City of Seattle Human Services Deparment (HCHN's 2nd largest funder)
United Way of King County
King County
State Public Health Funding
Medicaid Administnitive Match

In 2009, Health Care for the Homeless Network served 21,906 unduplicated homeless people.
This includes homeless people seen through contract partner agencies as well as homeless people
seen in public health centers. Ofthe 21,906 people, 52 percent were from communities of color.
49% of our clients lacked insurance of any kind, and 44% were on Medicaid.

The most common health problems of HCHN clients are mental health and substance abuse
disorders, skin disorders, heart problems, upper respiratory infections, musculo-skeletal
disorders, abuse-related issues, and acute health problems.

In 2008, the Bureau of Primary Health Care developed required clinical performance measures
for all federally qualified health centers. The HCHN 2009 Anual report details Public Health's

3 12
performance on eight clinical measures required by the grant.

ATTACHMENTS
1. 2009 Health Care for the Homeless Network Anual Report

4 13
 Health Care for the Homeless Network
Community Health Services Division

2009 Annual Report

l.~fi!~cK~et:~~e tl

il~~iit~~?1ifif%~1'~ .

14
 Table of Contents

A. Introduction.......... .............................................. .........................................................1

B. 2009 Accomplishments................................................ ......................... .....................3
C Program Resources (Federal, Local, Private) ............................................................ 6
D. 2009 Data Summary........................................................... .................................. ...... 7
Client Demographics
Health Characteristics
Public Health - Seattle & King County Clinical Measures for Homeless Patients
E. Death Data............... ....... ............... ........................ .... ......... ..... ...... ..... ........... ........ ... .15

F. Program Updates and Expansions ... ...... .................. ..................... .......................... .17
Chief Seattle Club
Housing Health Outreach Team
Medical Respite
Mental Ilness and Drug Dependency (MIDD)
Pathways Home
The REACH Program
Second Avenue Clinic
Third Avenue Center
HCHN Services for Homeless People Provided Within Public Health
Appendices ........ ...................................................... .......... .................... ........... ........... ..25
Major Service Sites............................................... .............. ....:............ ........... Appendix A
Core HCHN Shelter and Homeless Site Services........................................... Appendix B
Public Health Clinical Measures for Homeless Patients ............................... Appendix C
Acknowledgements...................................................... ................ .................................. 28

Questions about this report may be directed to:

Natalie Lente, HCHN Manager
206-263-8343, natalie.lentecækingcounty.gov
Health Care for the Homeless Network
Public Health - Seattle & King County
401 5th Avenue Suite 1000, Seattle, WA 98104/206-296-5091
http://ww. kinqcountv .Qov/health/hch

;~g:t?&~~~ŠS!Jfli~iZ.;~11~~1~Ei~£~J:~1L~~:;

15
 Ä. Introduction

The Health Care for the Homeless Network (HCHN) completed its 24th year of health service
coordination in 2009 for people living homeless and in supportive housing throughout Seattle
and King County. HCHN is pleased to provide
this report highlighting our work in 2009.

HCHN continued to align activities with the

Ten- Year Plan to End Homelessness in King
County and the United Way Blueprint to End
Chronic Homelessness. These key initiatives
influenced the implementation of a more
collaborative and systematic approach to
addressing homelessness.

Background
HCHN is organized through contracts with
community-based agencies, such as
community health centers, to provide services to homeless and formerly homeless individuals.
HCHN providers are currently located in over 40 sites throughout King County, primarily shelter
settngs (see Appendix A). These partnerships make up the core of
the network. HCHN also
encompasses the medical, dental, and case management services provided to homeless people
throughout Public Health - Seattle & King County's health centers and programs.

Homeless people are more likely than housed people to use the emergency department as their
regular source of care.1 Due to their lack of insurance coverage and other barriers, homeless
people are also far less likely to access regular preventive care and cancer screenings, such as
Pap tests and mammograms, than those who have coverage. By providing field-based
services, HCHN-funded providers help connect homeless individuals into mainstream services,
and often provide those services directly as they work to counter barriers to accessing care.

HCHN supports the right to qualiy health care for all people, with particular emphasis on access
to all aspects of health care for people living in poverty and experiencing isolation and
displacemenI. Staff and programs recognize the importance of providing integrated care
through interdisciplinary treatment teams that coordinate primary medical and dental care,
access to a health care home, mental health treatment and substance use treatment, affordable
housing, food programs, family and community support, and benefits and entitlements.

1 HomeJessness and Health: The Effect of the Course of Homelessness on Health Status and Health Care Use, American Journal of Public Health,
March 2007, VoL. 97, No.3.
2 HCHN Philosophy of Care. Available at: http://ww.kingcounty.gov/health/hch

;il~il~iS~Sf~i:1~~liJ~;Hi~~t~;~1~~~

16
Priority Actions

In 2008, HCHN worked with its 18-member community-based advisory Planning Council (see
Acknowledgements) and other stakeholders to gather input for a needs assessment from
individuals impacted by HCHN services, those not accessing services, and front line providers.

The results of the needs assessment led to the subsequent adoption of the following priority
actions for 2009-2014:

1. Ensure the application of evidence based practices that promote human dignity, empower
participants, and improve health outcomes.

2. Continue to provide services "where people are" including day centers, shelters, streets, and
supportive housing, working to improve access all geographic areas of King County where
people are experiencing homelessness.

3. Assure the provision of services that address the increasing acuity and complexity of health
care problems.

4. Address the need for increased access to information about health care resources and to
health care coverage.

5. Expand our awareness and focus on trauma informed care in recognition and response to
the high prevalence of cognitive and emotional impairments in the homeless population.

6. Continue to align investment strategies with those of the Ten- Year Plan to End
Homelessness in King County including alignment with the goal of the housing first /
supportive housing model to increase housing stability for persons with histories of chronic
homelessness.

2
i 7
B. 2009 Accomplishments
Enhanced Nursing Services in Supportive Housing

The Housing Health Outreach Team (HHOT) provided 912 nursing visits to 78 clients and
linked 46 clients to primary care as a result of increased nursing services at Catholic Housing
Services' Wintonia building to support the growing number of Sobering Center frequent users
placed in the building. Neighborcare Health

Established an Interdisciplinary Street Outreach Team

With funding support from the City of Seattle and United Way, the new REACH outreach
team moved 36 clients, found living outdoors, to permanent or transitional housing. Almost
1,200 service encounters were provided to 170 people in 2009. Neighborcare Health,
Evergreen Treatment Services and Pioneer Square Clinic

Expanded Case Management Services to Chemically Dependent Individuals

The REACH team enrolled 185 chemically dependent, chronically homeless clients into case
management, moved 95 clients into permanent housing and 53 into transitional housing,
linked 93 people to inpatient CD treatment and helped 138 people access primary care.
Evergreen Treatment Services

Increased Mental Health Outreach Services

Mental health providers served 435 people in downtown Seattle, south King County and east
King County, funded through Mental Ilness and Drug Dependency (MIDD) sales tax
revenue, with an emphasis on people leaving jails and other institutions. Valley Cities
Counseling and Consultation and Harborview Medical Center/Pioneer Square Clinic

Coordinated Emergency Response for People Living Homeless

In response to the novel H1 N1 influenza and the flood threats posed by Howard Hanson
Dam, HCHN developed a homeless response plan in preparation for both emergencies.
HCHN convened a stakeholder group of funders, government and health care agencies, and
advocates to guide the planning process.

Implemented Two Federal ARRA Grants

Public Health received two federal ARRA (American Recovery and Reinvestment Act) grants
to increase primary care and social work, support a site renovation for an expansion of
Medical Respite, create new exam rooms in a Public Health Center, purchase medical and
dental equipment, and help plan for electronic medical records in Public Health.

18
In 2009 Health Care for the Homeless Network (HCHN) continued to align activities with the
Ten- Year Plan to End Homelessness in King County and the United Way Blueprint to End
Chronic Homelessness.

Linked Homeless Peopl~ to Systems of Care

HCHN's outreach model locates providers where homeless people spend time and coordinates
access to health related services in mainstream systems.

. 2,076 people to primary care services

. 829 people to mental health services

. 490 people to chemical dependency

treatment

. 2,020 people to dental services at the

Downtown Public Health Dental clinic

. 2,226 households to support for Medicaid

and other entitlement applications

Prevented Discharge Back to the Streets

HCHN-contracted programs target high risk, vulnerable people who are often high utilizers of
hospitals, jails, and other public institutions.

Harborview's Medical Respite program, operated by the Pioneer Square Clinic at the
Salvation Army's Willam 'Booth shelter and YWCA's Angeline's Center, served 331 people
discharged from hospitals or clinics. They placed 81 clients into ~ransitional or permanent
housing at the completion of their respite stay.

The Tuberculosis (TS) program social worker assisted ten homeless TS patients to attain
permanent housing after completing TS treatment.

Valley Cities Counseling and Consultation and Pioneer Square Clinic provided mental health
services to 400 people targeting people leaving jails, hospitals and other institutions in
downtown Seattle and south and east King County.

4
19
 Provided Services to People Transitioning Out of Homelessness

HCHN supports community efforts to end homelessness through services that help people
maintain their housing, using proven models that employ interdisciplinary teams and fostering
coordination between partner agencies.

The Housing Health Outreach Team (HHOT) provided medical, mental health, and chemical
dependency services to 551 residents in ten supportive housing buildings in downtown
Seatte. Neighborcare Health and Evergreen Treatment Services

Pathways Home moved 44 families into housing. Providers continued to work with familes
for six months after they moved into permanent housing. Neighborcare Health and Valley
Cities Counseling and Consultation

The REACH Case Management team moved 95 clients to permanent housing. Case
management continues to help stabilze clients as long as they require support. The Street
Outreach team moved 81 people out of encampments and into permanent or transitional
housing or shelter. Those who required support to maintain housing were transferred to a
REACH case manager.

Conducted Network-Wide Quality Improvement Activities

All HCHN contracts are expected to include homeless populations in their overall quality
management activities. In addition, with support from the HCHN Planning Council, the program
conducts patient and provider surveys, chart reviews, and monitors extraordinary occurrence
forms related to deaths and other incidents.

HCHN family nurses updated their pediatric protocols. The protocols were presented at the
National Health Care for the Homeless meeting and are now available on the National Health
Care for the Homeless website: ww.nhchc.org.

Program Planning
Informed by the 2008 Needs Assessment, HCHN conducted a competitive request for proposal!
application process for the 2010-2014 grant period for contracted services. A process for
decision making regarding HCHN service sites was completed at the end of 2009. Criteria were
established to assess recommended changes or expansions to services as new funding sources
become available.

20
 C. Program Resources (Federal, local, Private)
The total HCHN program budget for 2009 was $6,407,256. Federal sources comprised just over
half the budget, and included the Health Care for the Homeless 330h grant from the Department
of Health and Human Services (HHS), McKinney funds from Department of Housing and Urban
Development (HUD), and short-term American Recovery and Reinvestment Act (ARRA) grant
funds. HHS funds are spread across multiple contracts, whereas HUD funds are designated for
the Pathways Home case management program for families and the Medical Respite program
for adults. HHS funds are allocated according to the annual application and plan submitted to
HHS-Bureau of Primary Health Care. The majority of funds were contracted to primary care
clinics, mental health, and substance abuse agencies.

Chart 1
Revenue Source Comparison 2005 and 2009

In $3. 5 __________.__.____n__..______._____________m~______.____----.--~--.--
i:
.2 $3.0

~ $2.5
$2.0 EI 2009
$1.5 EI 2005

$1.0
$0.5 --
$0.0
Federal Local Medicaid Private & Federal
Match Other ARRA

Local funding to HCHN increased

significantly beginning in 2007, Chart 2
whereas federal funds have remained HCHN Local Revenue Sources
fairly leveL. In 2009, local funds
comprised 38% of the budget \/S LeVý Medicaid
($2,452,676), up from 22% in 2005 King County 17% Match
($986,625). Local funders include the Expens e 15%
City of Seattle (HCHN's 2nd largest Funds
United Way
funder), United Way of King County, 1%
7%
King County Veterans and Human State PH
Services (VHS) Levy, and Mental 4%
Illness Drug Dependency (MIDD) DCHS
sales tax revenue. The increase in 3%
local funds has improved the ability to
leverage additional Medicaid
Administrative Match for eligible
services.

6
21
 D. 2009 Data Summary
This section highlights services provided byHCHN-contracted providers in 2009.3 Services were
provided by approximately 118 full time equivalent staff. Approximately half of the providers
were medical staff, including nurses and nurse practitioners, physicians and physician
assistants. The remaining providers were mental health counselors, substance abuse
counselors, case managers, outreach and engagement workers, and Medicaid enrollment
specialists.

Number of Clients Served and Visits Provided Chart 3

by HCHN Total HCHN Visits 2005-09

As ilustrated in Chart 3, HCHN contractors 60,000 .. .-------.---.-~-.-.----.-.----..--__. _____

provided 52,143 visits with clients in 2009, a 22% 50,000
increase since 2005. Similarly, HCHN 40,000
contractors served 8,830 individuals in 2009, an 30,000
8% increase since 2005. 20,000
10,000
These increases likely represent expanded
o
HCHN services due to new local funds.
2005 2006 2007 2008 2009

Chart 4
Clients Seen at HCHN and Public
Health Sites 2009
Public Health - Seattle & King County's Health
HCHN Centers provided 50,646 visits to 13,076 .
Sites homeless individuals in 2009, representing 60% of
40% clients served.
Public
Health
60%

Cha rt 5
Household Status of HCHN Clients
Household Status of HCHN Clients
Unknown
Single adult males make up the largest 8% Family
Young Adult
portion (64%) of individuals served by 17%
household type, similar to data (18 - 24 yrs)
9%
collected by Safe Harbors Homeless
Management Information System in Single Adult
2008. Male
45%
In total, 528 familes were served
representing 1,462 adults and children. Female
19%
3 Each time an HCHN-contracted provider sees a client a completed form is submitted to HCHN. A special client code is used across the network to
unduplicate client data.

'-;l~;ø4f;,ll;,~iÆi:&~i:J~:01~;Eš't.:~tt.t~~1

7
22
 Age and Gender of HCHN Clients

As shown in Chart 6, over the past 5 years, HCHN saw a 23% increase in the number of clients
age 40 and over, whereas those 39 and under have remained fairly stable.

The aging trend in the homeless

population has been identified in other Olrt 6
cities across the country.4 Although Increase in Older aient, ~ 2005~9
the barriers for elderly persons who
are homeless are similar to those of
5,SOO
younger homeless persons, they may
be more diffcult to overcome when
compounded by additional challenges
associated with aging, such as chronic
medical conditions, frailty, poor
mobility, and loss of hearing or
5,000
4,500
4,000---f;
~_::=::9
eyesight. 3,500
3,000
2005 2006 2007 2008 2009

Chart 7
Age and Gender, HC 20 Men served by HCHN in 2009
were older on average (46
3,500 years old) compared to women
3,00 (40 years old).
2,500
2,00 Two hundred and ten HCHN
1,500 clients were unattached youth,
1,00 meaning they were less than 18
50 years old and not living with
their parents. Nine percent
o
(790 clients) were young adults
0-11 12-17 18-24 25-39 40-54 55- 65+ between 18 and 24 years old,
living on their own.
mmale (60%) Elfemale (40%)

4 Hahn JA, Kushel MB, Bangsberg DR, Riley E, Moss AR. (2006). Brief report The aging of the homeless population: Fourteen-year trends in San
Francisco, Journal of General Internal Medicine, 21, 775-778 hltp:llww.ncbLnlm.nih,gov/pmclarticles/PMC1924700/. Accessed 6/9110

;E!¿;;~trtraìft~jlf~~~ì1~71~:Xj~rttr£F~j

8
23
 Race and Ethnicity of HCHN Clients

People of color represented a disproportionate percentage of HCHN clients in 2009 compared to

the population of King County (46% vs. 24%). As shown in Chart 8, the race distribution of
HCHN clients was similar to race distribution from other data sources
in King County that
collected demographic information on homeless individuals such as the One Night Count (ONC)
of People Who are Homeless in King County and the local Safe Harbors Homeless Management
Information System (HMIS).

Although 6% of individuals served by HCHN in 2009 were of unknown race, the majority of those
individuals were of Hispanic ethnicity with no other information. In total, 14% of HCHN clients
were Hispanic.

Chart 8
2009 HCHN Race Compared to
King County Homeless and Total King County Population
100%
I2 White

80%
m More than one race
and other
60%
o American Indian/
Alaska Natil.
40%
o Black/Afrcan
American
20%
li Asian/Pacific Islander
0%
lI Unknown
HCHN KC Shelters KC HMIS King County

Geographic Location of HCHN Services

The vast majority (89%) of all 2009 visits with HCHN clients were at sites within the City of
Seattle, which is where most HCHN services are focused. The higher proportion of HCHN
services focused in Seattle reflected the higher prevalence of the homeless population within
Seattle as well as funding support from the City of Seattle. In addition, some clients may have
traveled to Seattle from areas outside of the city to receive services.

Increases in local funding have enhanced services primarily in Seatte, but in othe(parts of King
County as welL. In the second half of 2009, the Mental Ilness Drug Dependency sales tax
funded two n~w mental health positions to offer mental health services and linkages to
individuals in east and south King County who were leaving jails, hospitals, and crisis facilties.

24
 History and Length of Homelessness of HCHN Clients

Homeless background information was available on about half the HCHN clients served. Of
those who reported this information, the number of clients who were homeless more than three
years increased steadily from 14% to 20% between 2005 and 2009.

The increase in length of homeiessness may be related to the effectiveness of HCHN providers
in targeting the chronically homeless population and program expansions such as the REACH
case management and outreach teams. Of the people who were homeless for more than three
years, almost all (93%) were single adults.

Fairly consistent over the past five years, 43% of HCHN unattached youth and adults had been
homeless three or more times. Also consistent over time, 11 % of HCHN clients in familes were
homeless three or more times.

Health Problems of HCHN Clients

Numerous studies have documented that homeless people experience many health problems at
rates higher than housed people. Among homeless people nationally, nearly 40% have some
type of chronic health condition. Homeless people are more likely to use the emergency
department as their regular source of care.5 Almost one out of nine homeless children
experience one or more asthma-related health conditions. In comparison, less than one in 15
middle-class children experience asthma-related health conditions.6

Data presented in this report represent clients seen by providers in the Public Health - Seattle &
King County HCHN program and appear to confirm that these health conditions are common.
As shown in Chart 9, the numbers with hypertension and diabetes have been increasing among
the homeless shelter and day program population served by HCHN in recent years.

Skin issues were the top

Chart 9
health concerns of HCHN
Selected Chronic Health Conditions,
clients 12 to 54 years old in
HCHN 2005-09
2009. Typical skin
conditions in in homeless 14%
adults include diabetic and 12% ---------.------~-- ------.-------- -- Hypertension
vascular ulcers, 10% .------------- --------------------- __ Diabetes
8% ____~___.___._______________________.._________._m'._._....._
abscesses, wounds,
infections (including
infections resulting from
itching related to bedbug
6%
4%
2%
~..u .
. _d.~.. · · -- Asthma
Atd At

bites), lice, and scabies. 0%

2005 2006 2007 2008 2009
Skin conditions were the
second most common
5 Homelessness and Health: The Effect of the Course of Homelessness on Health Status and Health Care Use, American Journal of Public
Health, March 2007, VoL. 97, No.3.
6 National Center on Family Homelessness http://ww.homelesschildrenamerica.org/repoa-child-wellbeing_health.php

.~K;ø;:;1

10
25
concern for clients under 12 years old. Typical skin conditions in this age group include
diaper rash, impetigo, lice, contact dermatitis, and eczema.

The top health concern of those 55 and over was cardiovascular disease. Cardiovascular
diseases include hypertension, high cholesterol, congestive heart failure, and stroke.
As shown in Chart 9, since 2005, the percentage of HCHN clients with hypertension
increased from 9% to 12%. The slight increase could be related to the aging population.
In addition, HCHN providers increased blood pressure screening efforts beginning in 2007,
which may have resulted in greater identification of hypertension.

Musculoskeletal concerns were ranked second for adults. Typical musculoskeletal

conditions in this age group include back pain, joint pain including arthritis, fractures,
sprains, and strains.

The third most common health concern of adults was respiratory conditions. Typical
respiratory conditions in this age group include colds, influenza, shortness of breath,
asthma, chronic obstructive pulmonary disease, pneumonia, and tuberculosis. The top
health concerns among children under 12 was respiratory conditions. Typical respiratory
conditions in this age group would include colds, influenza, asthma, pneumonia, and sore
throats.

Chart 10
Health Problem Prevalence Among HCHN Adults, 2009

sfemale limale
0% 10% 20% 30% 40% 50%
Skin
Musculoskeletal
Respiratory
Cardiovascular
Gastrointestinal
Endocrine
Genitourinary
Nutrition
Neurological

11

26
 Mental Health and Substance Abuse

The number of homeless people with mental health problems in King County is significant, with
about half of all existing HCHN patients having some type of mental health and/or substance
abuse disorder. In the 2008 HCHN online needs assessment survey, homeless service
providers ranked mental health and substance abuse services the top two areas of unmet need,
followed by primary medical care and dental care.

Of all age groups, mental health concerns were most common among women 25-54 years old.
Half of the women in this age group had a mental health issue addressed in a visit during 2009.
This decreased to 45% for women age 55 and over.

Compared to all health issues,

mental health was the top Chart 11
concern of 12-24 year olds. Mental Health and Substnce Abuse Prevalence
Thirt-two percent of all 18-24 Among HCHN Adults 2009
year olds had mental health El male 0 female
issues addressed during a visit
in 2009. The proportion of 0% 10% 20% 30% 40% 50%
young people with mental
health concerns jumped from Mental
8% in under 12 year olds, to Health
21% in youth 12-17 years old.
Substance
Substance abuse concerns Related
were addressed among 30% of
HCHN adults in 2009. Substance related issues were the most prevalent among men age 55
and over. Thirt-five percent of men in this age group had a substance-related issue addressed
in a visit.

In the 2008 provider survey conducted by HCHN in

its strategic planning process, respondents
identified the need for more integrated care
between service systems for people dually
diagnosed with both mental health and substance
abuse problems. Providers concurred that clients
who need the services of both systems are
frequently "bounced between them" and may not, in
the end, be served by either system. They
suggested continued training for health care providers regarding appropriate interventions for
participants with substance abuse issues and mental health issues including more access to
mental health supports.

Providers reported that comprehensive case management is a necessity for any client that has
it, many
chronic mental health, substance abuse, or language diffculties and that without

individuals will continue to fall through the cracks.

~:~~gjff~ffÆìtK4i~lm;w~%Z!\lt?nt~

12
27
 Spotlight on Veterans
Due to increased community and funder interest in homeless veterans, a few data snapshots are
presented here about veterans served by HCHN.

Miltary veteran status was not available for all HCHN clients. Providers report that clients are
sometimes reluctant to give this information during their initial visits.

Of adults 18 years or older, 839 clients identified themselves as having served in the U.S.
military. Based on HCHN encounter information, it is estimated that 20% of adults served in
2009 were miltary veterans. The number of veterans served by HCHN providers has increased
each year for the past 5 years.

2009 HCHN programs report the following veterans participation:

. REACH street outreach 25%

. REACH case management 21%

. Third Avenue Clinic 20%

. Medical Respite 19%

. HHOT 19%

Veterans served by HCHN were notably

older (average age of 53 years) compared
to all HCHN adult clients (43 years old).
According to census data, veterans who are
homeless are younger than the general
veteran population of King County.? Iraq
War era and younger veterans are over
represented among homeless veterans.8

7 American Community Survey 2006 and 2007

8 Veterans and Human Services Levy Outcome Evaluation of Strategy One, Attachment A, King County Department of
of Community and Human
Services

13
28
 Public Health - Seattle & King County
Clinical Measures for Homeless Patients
In 2008, the Bureau of Primary Health Care developed required clinical performance measures
for all federally qualified health centers. Public Health - Seattle & King County clinics are
established as a federal health center as a part of the scope of services for our homeless grant
under section 330(h) of the Public Health Services Act.

Below are two of the HRSA required measures for the 2010-2014 project-period. (The remaining
target goals and outcomes for 2009 are included in Appendix C of this report).

Increase the % of adult 72% 59%

patients with type 1 or 2 Total number of patients: 72 Total number of patients: 78
Diabetes in diabetes who are being Total number of patients in Total number of patients in random
homeless primary test and whose most random sample: 72 sample: 78
care patients recent HbA 1 cis .s9%. Number of clients with HgA 1 c Number of clients v.ith HgA 1 c
Baseline:72% under 9%: 52 under 9%: 45
Goal: 80%

Cardiovascular: Increase the % of adult 47% 60%

homeless patients with Total number of patients: 116 Total number of patients: 171
Hypertension in diagnosed hypertension Total number of patients in Total number of patients in random
homeless primary whose most recent random sample reviewed: 116 sample reviewed: 70
care patients blood pressure was less Number of clients with controlled Number of clients with controlled
than 140/90 (adequate blood pressure: 33 blood pressure: 42
control): Baseline:47%
Goal: 55%

Testing for hemoglobin A1c (HbA1c) is one of the best ways to assess whether one's blood
glucose is under control and to assess the risks of having health problems due to diabetes.
For the diabetes measure noted in the table above, the drop in number of controlled blood
glucose from 2008 wil be analyzed in 2010. There may have been fewer tests done; many
diabetic patients living homeless also have mental health issues which can become competing
visit priorities. Although taking insulin can be effective for blood glucose control, it requires
refrigeration and can be challenging to use when living homeless.

The increased level of control for the cardiovascular measure is likely due to a concerted effort in
2009 at Public Health - Seattle & King County clinics to properly assign patients the diagnosis of
hypertension and to assure they were correctly entered into our disease registry. Strategies were
implemented to help persons living homeless to be more successful with medication compliance.

In general, patients who are not engaged in a regular source of care often have poorer health
outcomes and measures of health. As patients rotate through our expanded outreach and case
management services, the overall goal is to identify a medical home and seek care more often,
which should result in improved outcomes.

14
29
 E. Death Data
HCHN annually reviews death information on all individuals who died in King County and who
were determined to be likely homeless according to the King County Medical Examiners Offce
(KCME).9 This information provides a glimpse into the harms and risks of living homeless.

In 2009, 73 individuals who died in King County were presumed to be homeless at the time of
their death. This is the lowest number of deaths reported by the KCME since this data was first
collected in 2004. Over the period 2004-09, 526 individuals in total were presumed homeless,
with a high of 110 deaths in 2006. Similar to prior years, the
average age of death in 2009 was 48 years old.

Homelessness May Increase Suicide, Homicide, and Fatal

Accident Risk

HCHN reviewed all deaths for which the KCME assumed

jurisdiction in order to determine if living homeless may make a
person more likely to die by suicide, homicide, or accident. The
information below compares homeless deaths to other deaths in
King County from 2004 through 2008. (Data is not yet available
for non-homeless deaths in 2009.)

Homeless individuals experienced a disproportionate number of deaths from accidents, suicides,

and homicides. Between 2004 and 2008,11 5% of deaths due to these causes were among
people living homeless. For a rough comparison, only 1 % of the King County population is
estimated to be homeless during the year. The most significant difference was in homicides: 8%
of homicides (30 deaths out of 365) were to individuals who were living homeless at the time of
their death.

Another notable difference was in deaths where serious doubt existed as to whether the injury
occurred with intent or as a result of an accident.12 In these cases, the KCME designates the
manner of death as undetermined. Eleven percent of such deaths were homeless individuals,
which may indicate that the circumstances related to living and dying homeless make it more
diffcult to determine the manner of death.
9 Only deaths that fall within KCME jurisdiction are included: 1) the cause was unnatural (accidents, homicides, and suicides); 2) the person died
suddenly when in apparent good health and without an attending physician in the 36 hours preceding death; 3) the circumstance waS suspicious,
unknown, or obscure; or 4) no next of kin or other legally responsible representative could be identified for disposition of the body.
10 Centers for Disease Control and Prevention. Heron M, Hoyert DL, Murphy SH, Xu J, Kochanek KD. Tejada-Vera B. Deaths: Final data for
2006. National Vitl Statistics Reports, 57(14). Released April17, 2009. Available at: http://ww,cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf. ,
11 This is excluding deaths were the incident leading to the deaths were outside of King County or unknown.
12 This may be due to lack of witnesses or prolonged time between death and discoveiy. King County Medical Examiner's Offce 2007 Annual
Report. Available at: hlt:llww.kingcounty.gov/healthservices/health/examiner.aspx.

WiJir~~'&~w.&'¥t0

15

30
Profile of Deaths Between 2004 and 2009 I
r----~------.----.---.--------.----------~--.---.--..-.-.--.-----.-----------------.-----..-.-.-------.-.--
i
I
The leading single cause of homeless deaths between 2004 and 2009 was acute intoxication i
i
(29% of deaths). In 2009, the number of deaths due to acute intoxication decreased (16 deaths I
i
compared to the high of 30 in 2005). I

Suicide comprised 8% of deaths in 2009, the highest year for suicides (11 deaths compared to
the low of 3 in 2007). However, homeless individuals experienced the lowest number of
homicides in recent years, which comprised 6% of deaths (2 compared to 11 in 2006).

Natural causes combined to total 40% of all deaths across all years. Non-intoxication related
accidents totaled 15% of all deaths.13 These other causes specifically included:

. Killed by cars or train (22 deaths) . Carbon monoxide-related such as

heaters and generators (6)
. Environmental exposure (9)
. Tuberculosis (2)
. Fires in temporary shelters (9)
. Crushed in compacting garbage can (1)
. Blunt force under unknown
circumstances (8)
. Drowning (7)

Of the 526 homeless deaths between 2004 and 2009, the majority (85%) were men. The
average age of death was 48 years and did not vary significantly between men and women.
Ages ranged from infancy to 93 years old, with the majority in the 40 to 59 year old age group.

The majority of the incidents that

led to the deaths between 2004 Chart 12
and 2009 occurred in Seattle Number of Homeless Deaths,
(73%). Homeless deaths occurred King County Medical Examiners Offce 2004-09
in other regions as well: 81 deaths
(15%) in south King County, 22 150
deaths (4%) in east King County, 110
100
8 deaths (2%) in north King
County. Incident locations outside 50
King County included 15 deaths o
(3%). In addition, the incidents in 2004 2005 2006 2007 2008 2009
17 deaths (3%) occurred in
unknown locations.14

13 Two percent of deaths were due to an unknown cause.

14 Three incidents occurred out-of-state; however, the deaths occurred at local hospitals and were under the jurisdiction of the KCMEO.

16
31
 F. Program Updates and Expansions

HCHN Contracted Services

This section highlights outcomes of selected HCHN programs. The activities described here are
newer and focus on particular sub-populations or emphasize the more recent incorporation of an
outcome focus on housing linkages and stabilzation.

Chief Seattle Club

Seatte Indian Health Board (SIHB) provides nursing

services at Chief Seattle Club, a site in Pioneer Square
serving predominately urban Indians. Services were
expanded in 2009 to assist clients with chronic and acute
ilnesses. Also new in 2009, the nurse can access the
SIHB electronic medical record system for improved care
coordination, the Emergency Services Patrol van (ESP)
is available to take clients to appointments, and a
refrigerator was added which makes TB skin testing and
vaccine provision, such as H1 N1 and seasonal flu,
possible. The nurse also coordinates the care of
chemically dependent clients with a REACH case
manager, newly sited at Chief Seattle Club.

Housing Health Outreach Team

The Housing Health Outreach Team (HHOT), formed in 2007, is an interdisciplinary team of
medical, mental health, and chemical dependency providers sited in 10 permanent supportive
housing buildings. Services are provided by Neighborcare Health and Evergreen Treatment
Services.

The team served 587 formerly homeless residents

living in ten buildings in downtown Seattle in 2009.
Of all clients, 206 (35%) were linked to primary
health care services and 385 clients (66%) linked
with mental health, chemical dependency, or dental
services.

The HHOT team also conducted several clinics for flu

shots, as well as foot care clinics in several of the
downtown buildings. These activities have proven to
be effective ways to connect individuals with
providers from multiple disciplines on the team.
Clients newly engaged through these clinics not only
connected with HHOT nursing or medical services,
but met with HHOT mental health and chemical dependency providers as well.

17
32
Medical Respite

HCHN contracts with Harborview's Pioneer Square Clinic to operate the Respite program for up
to 22 acutely ill homeless individuals at any time. For 15 years, the clinic has provided this care
to those who do not require hospitalization but who are too ill to stay in a shelter or on the street.
Services are currently provided in downtown Seatte to men at the Salvation Army's Willam
Booth shelter, and to women at the YWCA's Angeline's shelter. The program provides
recuperative care, linkage to primary care, mental health and chemical dependency case
management, and discharge planning.

The Respite program served 331 homeless

individuals in 2009.15 Sixt-six percent of the clients
were chronically homeless and almost 80% had
mental health and/or substance abuse problems.
The average length of stay in a respite bed was 18
days, a short period of time to accomplish goals set
out by the program.

The respite program placed 42 people in permanent

housing and 40 people in transitional housing in
2009, which was the highest number of housing
placements in the history of the program.

15 As reported for the HUD grant year February 1. 2009 - January 31, 2010.

JIí:r~l:~

18
33
Mental Ilness and Drug Dependency (MIDD) Funded Behavioral Health Services

HCHN received new funding from the King County Mental Health, Chemical Abuse and
Dependency Services Division (MHCADSD) Mental Illness and Drug Dependency Action Plan.
These funds provide mental health outreach services in east and south King County and
downtown Seattle. Through HCHN's contractors, Valley Cities Counseling & Consultation and
Pioneer Square Clinic, services are designed to stabilze people with mental illness and chemical
dependency, diverting them from jails and emergency rooms by linking them to ongoing
services.

For Seattle, the expanded mental health capacity was situated in two homeless service sites
downtown, YWCA's Angeline's shelter and the Compass Center's Adult Service Center,
although referrals are accepted from a broad range of homeless service providers. They provide
services to clients referred by the King County Jail release planners, REACH Case
management, and the shelter sites where they are located.

Similarly, services outside of Seattle prioritize clients of shelters and day programs that lack
behavioral health services and have significant numbers of clients with unaddressed mental
health or substance abuse conditions who are involved with hospitals, jails, and/or other crisis
facilities.

Pathways Home

The Pathways Home Program (PWH), also known as Medical Case Management for Children,
was developed in 1997 to promote housing stabilty for homeless families experiencing multiple
serious barriers. In 2009, Valley Cities Counseling & Consultation and Neighborcare Health
provided mental health, chemical dependency, nursing care, social work, and housing
assistance to familes throughout King County.

Until the family is

permanently housed
(and for six months
afterwards), the multi-
disciplinary team
provides continuity in
case management and
therapeutic services
regardless of where the
family is residing or how
many times they move.

During the past year,

99 familes were served,
with 47 new familes
entering during the year.
Fort-eight familes moved one level up the continuum of housing (56%). Thirt-five of those
families moved into permanent housing (41%) and nine moved into transitional housing. All

19
34
 families entering the program during the year (100%) were evaluated for health care coverage
and linkage to a primary care provider. Seventy-eight families (79%) met at least one goal of
their service plan.

REACH Outreach Team and Case Management Program

In 2009 REACH case management services were significantly expanded. Additional funding
from the Veterans and Human Services Levy, the City of Seattle Human Services Division, and
United Way of King County supported increased case management and contributed to the
creation of a new street outreach team.

Outreach Team: In 2009 the Outreach team made contact with over 450 people living outdoors
and referred 172 people to services. Of those engaged, 91 people entered a shelter or housing
and 110 people engaged with a REACH nurse. Experienced outreach workers were surprised
by the high numbers of people with serious, untreated health conditions. They found people to
be very receptive to services, resulting in high levels of engagement and success in linking them
to health care, treatment, as well as housing.

Case ManagementTeam: New funds resulted in expanding the scope of REACH services to a
case load of 320 people, 185 of them new in 2009. SerVices were made available to the entire
Seattle downtown core following years of service almost exclusively at Dutch Shisler Service
(OSSC). That notwithstanding, 145 users of DSSC were served by REACH in 2009. Their focus

:Ifgg~R~,ir#:~x~R%t'tA.t~~~~~f~:~iY'!!~~~

20
35
expanded to included homeless people using illegal drugs resulting in program collaborations at
sites including the Chief Seattle Club, the Needle Exchange, the Medical Respite program, the
High Utilizer Group, and Angeline's Center. In 2009, 209 case management clients were linked
to chemical dependency services, 156 clients moved to an improved housing situation with 95
moving to permanent housing, and 138 people engaged in ongoing primary care services.

Second Avenue Clinic

The Second Avenue Clinic has provided health services side by side with Public Health's Needle
Exchange for 10 years, through a contract with Pioneer Square Clinic. In mid-2009, these co-
located services, now renamed the Robert Clewis Center, moved to Public Health's Downtown
Health Center in Belltown.

The clinic focus is prevention of skin wounds that require hospitalization. Two providers, a
Physician's Assistant and a Nurse Practitioner, alternate on-site each afternoon, providing
wound care treatment for abscesses, cellulitis, ulcers, and infections. Care for other health
issues is available and clients can see the same providers at Pioneer Square Clinic. The vast
majority of clients were seen for wound care. Other common conditions included upper
respiratory infections, musculoskeletal disorders, and peripheral vascular disease.

Third Avenue Center

The Third Avenue Center (TAG), a health care clinic operated by Harborview Medical Center's
Pioneer Square Clinic, opened in 2004 to provide walk-in specialty health services five days a
week. TAC offers management of acute and chronic ilness, well adult exams, women's health
care, family planning, diagnostic testing, podiatry, and mental health services including
psychiatric services. The clinic primarily serves homeless adults and individuals without health
insurance. People with Medicare and Medicaid are eligible for services and sliding scale fees
are available.

21

36
 · In 2009, the Third Avenue Center (TAC) served 1,121 patients and provided an average of
3.1 visits per patient. Fift percent of T AC clients were women, which exceeds the
proportion of women in the King County homeless population overall (25%), and reflects
success in reaching out to women.

· Fift three percent of patients were people of color, similar to the overall racial make-up of
the local homeless population.

HCHN Services Provided Within Public Health for Homeless People

Oral Health

Since 2005, Public Health's Downtown Dental Clinic has prioritized services for homeless adults.
This work is supported by a federal oral health expansion grant from the Bureau of Primary
Health Care. In addition to self-referred patients, the clinic maintains partnerships with agencies
providing supportive services to currently and formerly homeless individuals. Case managers at
partner agencies refer and support clients in keeping their appointments and completing their
dental treatment plans.
Chart 13: 2009 Downtown Public Healt
In 2009, 79% of the patients Dental Patients (n=2,020)
(comprising 76% of the total visits) at
the Downtown Public Health Dental
Clinic were individuals who were Non-
homeless. As a result of the grant Homeless
implementation, the number of Patients
21%
homeless users at Downtown Public
Health has more than tripled since
2005. Of homeless patients receiving
periodic or comprehensive exams Homeless
between July 1, 2008 and December Patients
31, 2008, 28% completed treatment 79%
within 12 months.

Health and Safety Project: Communicable Disease and Health Education

A Public Health nurse on the HCHN team is dedicated to assisting homeless service agencies to
reduce risks associated with communicable disease. In 2009, she conducted 25 health and
safety workshops for 483 staff and volunteers. She also assured that 80% of City of Seattle _
funded shelters met best practice standards for communicable disease risk reduction.
Through the cooperation of community agencies, health care partners, and the Public Reserve
Corp, HCHN delivered over 2,400 doses of H1 N1 and seasonal flu vaccine to people living
homeless throughout King County.

22
37
Enhanced Tuberculosis (TB) Services

TB cases among the homeless have been

declining since the TB outbreak in the Chart 14
homeless community in Seattle in 2002- Homeless TB Cases in King County
2003. See chart 14.
40
For the past five years, the HCHN TB ~ 35
prevention nurse has provided technical : 30
assistance to homeless service agencies. ~ 25
~ 20
In that time, agencies have instituted TB
., 15
prevention policies that include annual E 10
risk assessments, staff TB screening, :i
z 5
increased awareness among staff through o
annual staff TB trainings and new staff 2002 2003 2004 2005 2006 2007 2008 2009
orientation, bed maps, education of
clients, and improved attention to
ventilation. In 2009, 250 staff in these agencies received TB training. In addition, HCHN has
supported a social worker in the TB Control Program to provide case management to people
with TB who are homeless, helping them get into permanent housing by the time they complete
TB treatment. Ten of those clients retained stable housing six months after completing
treatment.

23
38
The TB and Homelessness Coalition, a partnership between HCHN, the TB Control
Program, homeless services agencies, and funders, held three meetings in 2009 in their
work to prevent the spread of TB in the homeless community.

Emergency Preparedness for Homeless People

In order to address the potential H1 N1 influenza epidemic and possible flooding in south
King County, HCHN and King County Emergency Preparedness convened a stakeholder
group of agencies serving homeless people, funders, local and county governments, health
care agencies, and advocates.

The group prepared a community-wide

plan for coping with an epidemic, such
as H1 N1. The plan is multifaceted and
includes a surveillance system for
influenza-like ilness (Ill) at homeless
sites, a plan to isolate and care for
people with ill, the stockpilng of
supplies, a detailed communication
plan, and an antiviral distribution
system. A cornerstone of the
preparedness plan is the prevention of
influenza through health education,
emphasizing protective behaviors, and
vaccination.

The stakeholder group also examined

the potential impact of flooding from the Howard Hanson Dam. Although the dam did not
flood in 2009, the groundwork was laid for assisting homeless individuals when a flood is
imminent, and for developing an adequate response plan during and after the flood. This
information was made available to local and regional jurisdictions to guide planning.

~~rir~~J:t~t~~i~i*~t~qjfj

24
39
 Appendix A. HCHN Major Service Sites in 2009

Single Adults Familes

· Angeline's (YWCA) . Avondale Park
· Chief Seattle Club . Broadview Shelter
· Compass Center & Compass Cascade . Catherine Booth House (Salvation Army)
· Downtown Emergency Service Center . Domestic Abuse Women's Network
· Downtown YWCA . Eastside Domestic Violence Program
· Dutch Shisler Sobering Support Center . Family & Adult Service Center
· Katherine's House . First Place School
· Robert Clewis Center (formerly Second . Hopelink sites
Avenue Clinic at Needle Exchange) . Morningsong Family Support Center
· St. Martin de Porres Shelter (Catholic . New Beginnings
Housing Services - CHS) . Providence Hospitality House
· Third Avenue Center (at YWCA Opportunity . Sacred Heart
Place) . South King County Multi-Service Center
· Willam Booth Center (Salvation Army) sites
· Union Gospel Mission Family Shelter
Housing Health Outreach Team (HHOT)
Sites · YWCA East Fir Street Shelter
· Frye Apartments(CHS) · YWCA family sites countywide
· The Gatewood (Plymouth Housing Group
PHG) Certain visits also take place in the client's
home (once housed), streets, encampments,
· Kerner-Scott House (DESC)
and other sites.
· The Lewiston (PHG)
· The Morrison (DESC)
· Plymouth on Stewart (PHG)
· Scargo Apartments(PHG)
· Simons Senior Apartments (PHG)
· The Westlake (CHS)
· The Wintonia (CHS)

Youth and Young Adults

· 45th Street Clinic (Neighborcare Health)
· Country Doctor Youth Clinic (through UW
Adolescent Medicine Clinic)
· Y outhCare Orion Center

25
40
 Appendix B. Core HCHN Shelter and Homeless Site Services
Programs for Families

· Valley Cities Counseling & Consultation manages the Familes in Shelters programs
providing mental health and chemical dependency services to families who are enduring
homelessness in Seattle and in South King County.

· Carolyn Downs Family Medical Center - Homeless Team provides on-site nursing
services to women and familes who reside at shelters/transitional housing sites in Central
Seattle.

· Odessa Brown Children's Clinic provides on-site primary health care to children who
attend First Place School and Wellspring Family Services Early Learning Center (formerly
Morningsong Day Care) in Seattle

· HealthPoint provides on-site nursing services to women and familes who reside in shelters
and transitional housing sites in North, East and South King County.

· Neighborcare Health/45th Street Clinic provides on-site nursing and mental health services
to women and familes who reside in shelters and transitional housing sites in North Seattle.

· YWCA Health Care Access advocates help people apply for benefits and link them to
medical care, including eye exams, glasses, prenatal care and dentaL.

Programs for Youth and Young Adults

· 45th Street Clinic Homeless Youth Clinic is a medical clinic of Neighborcare Health for
homeless youth and young adults aged 12-23 in the Wallngford neighborhood of Seattle.

· Country Doctor Free Teen Clinic is a medical clinic for homeless youth and young adults
aged 12-23 in the Capitol Hil neighborhood of Seattle.

Programs for Single Adults

· The Bridges Program (Valley Cities Counseling & Consultation) provides mental health
outreach services to homeless sites in North, East and South King County.

· Pioneer Square Clinic (Harborview Medical Center) provides mental health and nursing
services to homeless adults in shelters and transitional housing sites in downtown Seattle

· HealthPoint provides nursing services for formerly homeless adults living in South County
Housing First units managed by Sound Mental Health (SMH) and King County Housing
Authority. Residents are referred to housing from the SMH Projects for Assistance in
Transition from Homelessness (PATH) program. Medical case management services are
also provided to clients of the Public Health - Seattle & King County South King County
Mobile Medical Van.

26
41
 Appendix C. PHSKC Clinical Measures for Homeless Patients
I/:.C::.\'d.",:,/'.:,.
.. .:, :'.' :.:.: .~.-,..-:~
Diabetes: Increase the % of adult pa-
Diabetes in tients with type 1 or 2 diabe-
homeless primary tes who are being test and
care patients whose most recent HbA 1 c is
2.9%. Baseline:72%
Goal: 80%
Cardiovascular: Increase the % of adult
Hypertension in homeless patients with
homeless primary diagnosed hypertension
care patients whose most recent blood
pressure was less than
140/90 (adequate control):
Baseline:47% Goal: 55%
Cancer: Increase the % of homeless
Pap testing for women ages 21-64 (24-64 in
homeless women 2009) who have a pap test
during the same year or the
two previous years.
Baseline:70% Goal: 75%
Prenatal and Among homeless patients,
Perinatal Health: increase the % of birth
Birth weight for weights of more than 2500
infants of home- grams to prenatal patients.
less primary care Baseline:90%
patients Goal: 92%
Prenatal and women
Increase the % of
Perinatal Health: who receive prenatal care
Early prenatal and initiate care with our or-
care for homeless ganization who start care in
pregnant primary the first trimester.
care patients Baseline: 53%
Goal: 75%
Child Health: % of 2 year old homeless
Childhood children who are up to date
immunizations for on immunizations.
homeless children Baseline: 78%
in primary care Goal: 80%
Behavioral % of homeless chronic
Health: inebriates served by REACH
case management team who
engage in substance abuse
treatment. Goal: 55%
Oral Health: % of homeless dental
patients at Downtown Public
Health with a comprehensive
oral exam who have com-
pleted their treatment plans
within a 12 month period.
Goal: 35%
" '0~~;.t)¿tfgA-t+~~fiEitR_Rr~,;~lr¿:t~~~~iriUif~
....,- .,.:
..ZUUlS
,.-c.-\H .... . .,.' C .c' .
72%
Total number of patients: 72
Total number of patients in
random sample: 72
Number of clients with HgA 1 c
under 9%: 52
47%
Total number of patients: 116
Total number of patients in
random sample reviewed: 70
Number of clients with controlled
blood pressure: 33
70%
Total number of patients: 1672
Total number of patients in
random sample reviewed: 70
Number of clients tested: 49
90%
Total number of patients: 11
Total number of patients in
random sample reviewed: 11
Number of clients with infants with
birth weights more than 2500
Qrams: 10
53%
Total number of patients: 15
Total number of patients in
random sample reviewed: 15
Number of clients with receiving
first trimester prenatal care: 8
78%
Total number of patients: 91
Total number of patients in
random sample reviewed: 91
Number of children up to date on
immunizations: 71
50%
N=132
28%
N=100 (chart review sample)
27
IT.,.:I .', ..\) i." '.. .,..,..i(:/Fi ....i
59%
Total number of patients: 78
Total number of patients in
random sample: 78
Number of clients with HgA 1 c
under 9%: 45
60%
Total number of patients: 171
Total number of patients in
random sample reviewed: 70
Number of clients with con-
trolled blood pressure: 42
63%
Total number of patients: 1043
Total number of patients in
random sample reviewed: 70
Number of clients tested: 44
42%
Total number of patients: 7
Total number of patients in
random sample reviewed: 7
Number of clients with infants
with birth weights more than
2500 orams: 3
47%
Total number of patients: 17
Total number of patients in
random sample reviewed: 17
Number of clients with receiving
first trimester prenatal care: 8
77%
Total number of patients: 94
Total number of patients in
random sample reviewed: 94
Number of children up to date
on immunizations: 73
71%
N=145
32%
N=1249
42
 Acknowledgements
Contract Partners
· Country Doctor Community Health Centers
· HealthPoint (formerly Community Health
Centers of King County)
· Evergreen Treatment Services
· Odessa Brown Children's Clinic
· Pioneer Square Clinic - Harborview Medical
Center
· Neighborcare Health (formerly Puget Sound
Neighborhood Health Centers)
· Seattle Indian Health Board
· University of Washington Adolescent
Medicine
· Valley Cities Counseling & Consultation
· Salvation Army Willam Booth Center
· YWCA of Seatte-King-Snohomish County
Funders
· City of Seattle Human Services Department
· King County Department of Community &
Human Services
· King County Veterans and Human Services
Levy
· King County Mental Ilness and Drug
Dependency Sales Tax
· United Way of King County
· U.S. Department of Health & Human
Services, HRSA, Bureau of Primary Health
Care
· U.S. Dept of Housing & Urban Development
· Phoebe W. Haas Charitable Trust
· Small Changes (calendars for clients)
Public Health - Seatte & King County
· Downtown Public Health Dental Clinic
· Tuberculosis Control Program
Y outhcare
· Robert Clewis Center/Public Health HIV/AIDS
Program
· King County Medical Examiner
· Assessment, Policy Development and
Evaluation Unit
· Emergency Preparedness
· Public Health Centers, Community Health
Services
28
2009 HCHN Planning Council Members
Carole Antoncich, Homeless Housing
Coordinator, King County Department of
Community and Human Services
Maureen Brown, MD, Swedish Family Practice
Residency Program, Downtown Publ.ic Health
Center
Leticia Colston, MSW
Mark Dalton, Administrator, Washington State
Department of Social and Health Services,
Bellown Community Service Offce
Jerry DeGrieck, Public Health Policy Manager,
City of Seattle Human Services Department
Sinan Demirel, Executive Director, Rising Out
of the Shadows
Charissa Fotinos, MD, Medical Director,
Public Health - Seattle & King County
Greg Francis, Consumer Representative
MJ Kiser, Program Director, Compass Center
Ed Dwyer O'Connor, Clinic Practice Manager,
Pioneer Square Clinic Harborview Medical
Center
linda Rasmussen, Regional Director, South
King County, YWCA of Seattle, King County &
Snohomish County
Eva Ruiz, Community Member
Sheila Sebron, Consumer Representative
Susan Rogel, Director of Homeless Services,
Photo Credits
· Neighborcare Health
· Evergreen Treatment Services REACH
program
· Public Health - Seattle & King County
43