7
Street roots
June 24, 2011
HEAD CASES, fro m page 1
behaviors.
Liora Berry of Cascadia Behavioral
Healthcare says that spontaneous anger can
be a misunderstood symptom of someone :
with TBL “It’s the inconsistencies in brain
trauma that make it so difficult for providers
to understand,” says Berry. “It’s easy to get
the impression that they’re just not
interested in services.”
Andrew Ellis, clinical director of the Brain
Injury Rehabilitation Center in Beaverton,
gives another example of the difference
between mental illness and TBI. “Someone
who is clinically depressed will have days
when their mood is better and problems
dissipate,” says Ellis. “For someone with a
TBI, those problems won’t dissipate.”
Personal acquaintances can help by
identifying changes in pre-TBI and post-TBI
behavior, says Ellis. Some of his TBI patients
are “floored at the changes others perceive.”
Screening for TBI does not have to be
complicated. The Defense and Veterans
Brain Injury C enter’s “Brief Traumatic Brain
Injury Screen” uses three basic questions to
detect TBI:
1. Did you have any injury(ies) during your
deployment from ... fragm ent... bullet ...
b la st... ?
2. Did any injury received while you were '
deployed result in ... being dazed, confused
or “seeing stars”... losing consciousness ...
having any symptoms of concussion
afterward (such as headache, dizziness,
irritability, e tc .)... ?
3. Areyou currently experiencing any of
the following problems that you think might
be related to a possible head injury ...
headaches, dizziness, memory problems,
balance problems ... irritability, sleep
problems?
Ellis believes such a basic screening could
be easily adapted for the homeless
population.
Mellani Calvin, program director of a
disability benefits training and' consulting * r
company and former manager of Central City
Concern’s B.E.S.T. program, says she
interviews homeless clients for personal
history and does a series of basic cognitive
tests to look at levels of functioning. “I
always ask about TBI,” says Calvin. “When I
was at B.E.S.T., about hah of our clients
answered yes to mild TBI, and about a
quarter to severe-knocked-out-cold TBI.”
“Ideally, I hope we get to the point (with
homeless health care) where we take time to
ask questions and do mini-assessments ...
starting with front door staff,” says Berry. “I
don’t know how often that’s actually
happening.”
“What clearly has to happen when TBI-
folks get into housing is everybody has to
understand what TBI is,” says Dr. Jim
O’Connell-, president of Boston’s Health Care
for the Homeless Program. He cites the
program’s Barbara McInnis House, a 104-bed
medical respite care center, as a creative
outlet for times when tensions arise between
clients with TBI and staff at other shelters.
“If you understand their outbursts as a
manifestation of their illness and expect
GOOD, BAD UGLY, fro m page 1
Boston’s Health Care for the Homeless
Program. “If Pm seeing someone at the
Pine Street Inn shelter on a Friday night
and they had been seen a t a soup kitchen
the day before, I see that on their record.”
The Homeless Youth Service Continuum
in Portland is another example of shared
systems, albeit a micro-approach that only
targets homeless youth ages 13-21. Outside
In, New Avenues for Youth and Janus Youth
Programs double-enter records into a
common database that is available to
several youth homeless providers.
Double-entering gets challenging when
organizations are interested in tracking
different things, often motivated by grant
reporting, or when agencies have different
definitions of data points, says John Duke,
health clinic director a t Outside In.
MiVIA is an online health database
launched in California in 2003 to provide
electronic health records for migrant
Some of those lifestyle changes can be
small. “There’s little things that can help
with TBI, like keeping a notebook, calendar,
watches, all things that are not in the
backpack of a homeless person,” says Berry.
Another realistic treatment method is re s t
“Rest is critical to treating TBI, says Ellis.
“Routine and structure having a consistent
abode can be key, he says.
In Portland, the new Bud Clark Commons
takes TBI symptoms, such as memory loss,
disorganization, weak social skills and poor
anger management, into account when
prioritizing who receives beds, which will
provide a unique recovery space for TBI
clients.
Funding surveys
them, you can set up an environment that’s
conducive. Otherwise, they’re more likely to
get evicted.”
Taking the time
“With most systems — whether it’s
medical, mental health or social work — you
have a brief amount of time to talk to
someone,” says Berry. When providers
spend more time with clients, they build
trust, which can make all the difference in
the cognitive impairment cases, says Berry.
“Sometimes our staff begins to pick out
them es of What’s going on with people they
see over time. Then we have to sort out how
we can help them,” says Berry.
Steve Mattsson, manager of Hooper
Sobering Center, agrees wholeheartedly.
“Getting to know individual people makes *$? *
huge difference when it comes to recognizing
brain injury,” Says Mattsson. “Homeless
people are notoriously poor historians, but
our EMTs will often recognize a person and
remember his history.”
Berry cites techniques developed by
psychologist Virginia Luchetti to help TBI
clients: “First you have to address daily living
by helping them figure out how to use the
phone, handle money, take public transit,
then you have to work on social skills,
concentration and memory.” Luchetti’s
strategy emphasizes spending quality time
with a TBI patient by removing distractions
and framing questions respectfully.
Connecting health care systems
“Electronic health records would be a
significant tool if ^omeone walks into one
clinic and has been going to another clinic
without making a connection himself,” says
Sam Chase, executive director at Coalition of
Community Health Clinics.
But we’re not there yet, (see “The Good,
The Bad and The Ugly: Tracking Health Care
workers, whose transient lifestyle means
discontinuity in health care. The mission of
MiVIA revolves around saving time and
money by avoiding duplicate tests. Web-
based records like MiVIA have enormous
potential among the homeless population.
for the Homeless”). Each safety-net agency
in Portland has its own independent database
that is typically incompatible with other
databases. Shelter records, medical records,
mental health records, substance abuse
records and incarceration records are all
separate islands, making it daunting to track
care across multiple systems.
When it comes to TBI, the notorious
“invisible disease,” sharing health records is
especially im portant One study by the San
Francisco Department of Public Health
found that a homeless person is much more
likely to self-report asthma, heart disease,
diabetes and substance abuse, than to self-
report TBI.
Realistic treatment plans
. “We need, to expand services like
. .
neuropsychevaluationsand treatm ent and
rehabilitation. Having something effective to
do once a person screens for brain injury
might increase the chance the practice is
done more routinely,” says Caughlan.
“Psychiatric treatm ent and speech and
occupational therapy are critical,” says Ellis,
although he admits those resources are
more challenging for homeless clients, “Even
40-hour-a-week, middle-class people may not
get rehab covered depending on their flavor
of insurance,” he says.
“The more integrated, one-stop-shop
health care we can provide for the homeless,
the better. One vision I have is offering
neuropsych testing and occupational therapy
in-house (at Health Care for the Homeless
Baltimore),” says Caughlan.
Both Caughlan and Ellis say a more
realistic, key step to helping a TBI patient is
identifying their deficits and creating a
compensation plan made up of small goals.
“One of the hardest parts of rehabilitation
for a TBI survivor is readjusting your lifestyle
and letting go of goals you had before your
injury,” says Ellis.
“HMIS could potentially work like CCMS
if it collected information from non-HUD
safety-net agencies and included clinical
records,” says Maria X. Martinez, who
headed the creation of CCMS and works in
the Director’s Office of the Department of
Public Health in San Francisco,
The bad
“We’re trying to make sure all clinics are
connected but it depends on which clinic
you go to,” says Chase.
“Right now, (healthcare for the homeless)
isn’t really tracked that easily,” says Duke,
who must request records from other clinics
once patients tell him they’ve been to those
dinics.
Portland’s closest thing to a homeless
tracking system is the Homeless National
Information Systems (HMIS), a U.S.
Department of Housing and Urban
Development (HUD) sponsored program.
HMIS is limited, however, because only date
from HUD-funded agencies is collected. And
clinical information is excluded.
And the ugly
“There are not always incentives to
create a common database for homeless
health care,” says Duke. “Hospitals are
competitive.”
“Even though it is completely legal to
share records through electronic databases,
physicians from different hospitals get
nervous about increased liability,” says
Martinez, a former specialist in health
information privacy laws. “Picking up the
phone to discuss a case is one thing, but
codifying information is unnerving for
institutions.”
With the exception of substance abuse
Whether the reasoning is to lower health
care costs, reduce rates of incarceration,
strengthen families, or reduce homelessness,
studying TBI on the streets is a worthy
funding cause.
Dr. Theresa Petrenchik, who helped lead
two studies that found significant rates of
TBI among the homeless, believes cities
need to survey for TBI on the streets.
Whether the surveys focus on the rate of
TBI, links to other health problems, patterns
of clinic visits, or financial costs of
addressing TBI, “the p o in t... is there is now
enough evidence to suggest a link between
(TBI) and homelessness,” says Petrenchik.
“Each city m u s t... decide what it will do in
response.”
Doctors Stephen Hwang and Barbara
Wismer, both proponents of documenting
TBI among the homeless, independently
estimate that $10,000 is the minimum
required to conduct a barebones TBI survey
in a single city.
Hwang and Wismer are part of a national
team of researchers interested in conducting
a 10-city study of TBI. They are hoping to
receive $10,000 - $300,000, with the ultimate
goal to develop an intervention to improve
the health of homeless patients with TBI.
Making the dream a reality
“I just feel like this is a huge issue. If we
as a community and as a nation wrapped our
heads around (TBI) we could create real
services and be more respectful rather than
jumping to conclusions,” says Berry.
“My dream is that cognitive rehabilitation
will become as available as mental health and
substance abuse treatm ent to people who
need it,” says Caughlan, “Realizing this
vision isn’t solely a funding problem; we
need to also develop a trained workforce, and
infrastructure — none of which will happen
overnight
“I don’t blame anyone for not wanting to
look at this. It’s a bit daunting if you take in
the totality. At the same time, we provide
these other treatm ent services for very good
reasons: to help people maximize their
potential and to reduce the harm in the
community that is linked to untreated
disease.
“These are reasons enough to get busy
building the work-force and infrastructure.”
records, however, records from social
workers, primary care physicians,
psychiatrists, case managers and shelters
are all fair game to share among providers
of care, says Martinez.
Martinez will be the first to admit that
even CCMS has major flaws. Despite being
an enormous wealth of information about a
homeless client, CCMS usually comes in
second to an agency’s own database. Social
workers might make time to look at both
sets of records, but physicians who are
pressed for time may nob says Martinez.
Then, there’s the question of what to do
after data is shared, “So-what-now-what?”
asks Martinez. “What’s the next step?
We’ve seen that sharing information alone
doesn’t change practice. (Sharing
information) is a whole new way of
delivering care because you don’t just have
your toolkit; you have many agencies’
toolkits. So we’ve got to change our
protocols and our whole way of thinking.”