Kings county .Washington, plan to ban e-cigarettes

8/9/2019 Kings county .Washington, plan to ban e-cigarettes

1/43

tQKing County

King County 1200 King CountyCourthouse516 Third AvenueSeattle, WA 98104Meeting AgendaBoard of Health

Metropolian King County Councilmembers: Julia Patterson, Chair;Kathy Lambert, Vice Chair; Jan DragoAlternate: Reagan DunnSeattle City Councilmembers: Sally Clark, Richard Conlin, Nick LicataAlternate: Mike O'Brien

Suburban Elected Members: Ava Frisinger, David HutchinsonAlternate: Dan ShermanHealth 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 10011. Call to Order2. Roll Call3. Announcement of Any Alternates ServinQ in Place of ReQular Members4. Approval of Minutes of June 17, 2010

5. Public CommentsBriefings

6. 10-816 Tobacco Policy Progress Report from the SOH Tobacco Ad Hoc CommitteeScott Neal, Tobacco Prevention and Control Program Manager, Public Health - Seattle &King County

7. 10-817 2009 Health Care for the Homeless Network Annual ReportNatalie 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 CouncilGreg Francis, Co-Chair, Health Care for the Homeless Network Planning Council

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


2/43

Board of Health Meeting Agenda July 15,2010

8. Chair's Report9. Board Member Updates

10. Administrator's Report11. Other Business12. AdjournmentIf you have questions or need additional information about this agenda, please call 206-263-8791, orwrite to Maria Wood, Board of Health Administrator via email at maria.woodckingcounty.gov

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


3/43

tiing Count King County 1200 King CountyCourthouse516 Third AvenueSeatte, WA 98104Meeting MinutesBoard of Health

Metropolitan King County Councilmembers: Julia Patterson,Chair;

Kathy Lambert, Vice Chair; Jan DragoAlternate: Reagan DunnSeattle City Councilmembers: Sally Clark, Richard Conlin, Nick

LicataAlternate: Mike O'BrienSuburban Elected Members: Ava Frisinger, David HutchinsonAlternate: Dan Sherman

Health Professionals: Ben Danielson, MD, Frankie T. Manning,RN, M.A, Ray M. Nicola, MD, MHSA, FACPMStaff: 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 1001DRAFT MINUTES

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

2. Roll CallPresent: 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 MembersBoardmember Sherman attended the meeting.

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

5. Public CommentsThe following person spoke:Dr. Victor Barry

King County Page 1 3


4/43

Board of Health . Meeting Minutes June 17, 2010

6. Director's ReportDr. David Fleming, Director, Seatte-King County Deparlment of Public Health, reporledon 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 reporledthat requests for proposal for CPPW grants have been received and the process isclosed. The Deparlment received 77 proposals for healthy eating programs and 18proposals for tobacco prevention programs. The grants wl be made later this summer.

Briefings7. 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 onthe H1 N1 flu outbreak and the responses to it.Dr. Fleming answered questions of the Board.

8. Chair's ReportThe Chair reporled on the Goat HI Giving Garden, which county employees maintainduring lunch breaks and free time, to promote good health and cut the rising trend ofhealthcare costs. The produce from the Garden wl be donated to the Pike Place SeniorCenter.

9. Board Member UpdatesBoardmember Frisinger reporled that at the city of Issaquah staff meeting Seatte Tilthmade a presentation on community gardening.

10. Administrator's ReportBoard Administrator Wood had no reporl.

11. Other BusinessThere was no other business to come before the Board.

12. AdiournmentThe meeting was adjourned at 2:20 p.m.

Approved this day of

Clerk's SignatureKing County Page 2 4


5/43

tling CountyKing County Board of HealthStaff Report

Agenda item No: 6Briefing No: 10-B16 Date: July 1S, 2010Prepared by: Scott Neal, Joy HamiltonSubject: A briefing on the policy recommendations of the Board of Health Tobacco PolicyCommittee.Purpose: The purpose of this briefing is to report back to the Board on the work of theTobacco Policy Committee and to propose policy changes to the BOH code that woulddecrease health inequities related to tobacco use and provide new opportunities to decreaseand prevent tobacco use in King County. Full code revision language and policy papers willbe prepared for the Board of Health meeting in September.Summary: The Tobacco Policy Committee was convened to develop new tobacco policiesthat respond to current opportunities and tobacco disparities in King County. TheCommittee is recommending new policy to address smoking in public places/places ofemployment, place restrictions on sale and availability of tobacco products, and to addresssecondhand 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 andopportunities related to tobacco use in King County. The presentation included currenttobacco use and mortality data, suggestions for policy responses to this data and new policyoptions created by the Family Smoking Prevention and Tobacco Control Act. The Boardconvened the Tobacco Policy Committee.Committee membership includes BOH members Dr. Bud Nicola (chair), King CountyCouncilmember Jan Drago, Seattle City Councilmember Sally Clark and Lake Forest ParkMayor David Hutchinson, and Gary Johnson, PHSKC Prevention Division Manager. Thisreport details the recommendations of the Committee to the Board of Health after twoworking meetings.Policy Recommendations: The Committee recommends three areas of policy action:improving smoking ban in public places/places of employment, restricting sale andavailability of tobacco products and addressing secondhand smoke exposure in multi-unithousing.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 thatprohibits smoking in public places and places of employment. The BOH has the authority toenact local regulations to implement this law, including defining terms that are part of thestate law. The following three revisions have been identified by the committee as necessaryimprovements that would provide for more effective education and enforcement activitiesthat would achieve higher compliance.

1 5


6/43

1. Clarify existinq KCBOH Code 19.03 by includinq definitions to kev terms such asemployee, private facility and enclosed area. The King County ProsecutingAttorney'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 morespecific legal framework for appeal processes.2. Adopt increased fines and escalating fines for large venues impacting siqnificantlymore people than typical establishments. Currently, all establishments, regardless ofsize, face a $100 per day fine for violations of Code 19.03. This proposed actionwould allow for larger fines at venues that impact a substantially greater number ofpeople and are often only in operation at limited times/days. Examples of theseestablishments are stadiums, theaters, and other entertainment venues. Theseestablishments create health risks for a substantially greater number of people whenthey fail to enforce Washington's prohibition of smoking in public places and placesof employment. Their event-limited hours allow only for occasional enforcement bythe health department, which often is not substantial enough to drive compliance.larger fines for these establishments would reflect the larger risk and give PHSKCeffective enforcement options in cases of limited enforcement opportunity. The King

County Prosecuting Attorney's Office will help with gUidance on the appropriate levelof 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 complaintreceived by PHSKC. Subsequent complaints lead to onsite inspections and the firstviolation observed during an inspection leads to an official warning and requires re-

inspection to verify compliance. A violation Portionof $95,320 inspection costobserved in re-inspection (and all attributed to multiple inspectionssubsequent violations) leads to a $100 fine.While most establishments come intocompliance after one inspection, a smallnumber of establishments with repeatedviolations generate over half of the totalcost of PHSKC enforcement related tosmoking in public places/workplacesenforcement (see adjacent chart). Re-inspection fees are necessary to offset thecosts of multiple inspections for these repeat violators. Repeat violators cost morebecause they require more Public Health staff time as well as assistance from legalcounseL. Importantly, escalating fines would also increase the incentive forcompliance for repeat violators that have not responded to repeat $100 fines.

September 2007-present

Sale and Availabilty of Tobacco Products (SOH Code 19.04)The following two proposed code enhancements restrict the sale and availability of tobaccoproducts by addressing products that target youth and by providing effective cessationmessages to people using tobacco at the point of sale.

1. Prohibit the sale of flavored alternative (non-ciqarette) tobacco products andelectronic cigarettes.a. The Family Smoking Prevention and Tobacco Control Act of 2009 banned anyflavor but tobacco or menthol from cigarettes beginning in September 2009.

2 6


7/43

New SOH policy canapply similarrestrictions to all othertobacco products(cigars, cigarillos andsmokeless). Thiscomplementary policyis necessary sinceyouth in King County use alternative tobacco products more frequently thancigarettes! and because tobacco products with candy flavors like grape andmint hold high appeal for youth. Restricting these products to the flavor oftobacco will reduce youth initiation of tobacco use by eliminating a line ofproducts designed to recruit youth by using packaging similar in coloring andlabeling to candy and by masking tobacco's flavor and harshness with candyflavors. This policy would also limit the flavors of new future products likeCamel's flavored Orbs (similar to tic-tacs), Sticks (toothpick-like shape) andStrips (similar to breath strips) that have candy-like flavors as part of theirappeaL. While the Board of Health has the authority to revise Code 19.04 toinclude 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 brandsfound some of the same toxics and carcinogens as in traditional cigarettes.2A ban on the sale of manufactured nicotine products not regulated by the FDAprotects King County residents from products like the e-cigarette, that are notproven to be safe and in laboratory investigation contained harmful additives.Electronic cigarettes, or e-cigarettes, are battery-powered devices thatvaporize nicotine, flavoring, and/or other chemicals into an inhalable vapor.The product is marketed for a variety of uses including as a cessation aid andas an alternative to tobacco in places where smoke is not permitted. None ofthese uses have been approved by the FDA. There continues to be noscientific support for the anecdotal claims that e-cigarettes are an effectivesmoking cessation aid) There is concern that electronic cigarettes mayappeal to youth because of their high-tech design, easy availability online orvia mall kiosks, and the wide array of flavors of cartridges including chocolateand mint.4 The FDA has classified the e-cigarettes it had examined ascombination drug-delivery products that require approval before being legallysold in the US. Currently, the FDA's jurisdiction over these products is beingchallenged 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 ofelectronic cigarettes and this action would be consistent with the FDA'sintentions.

2. Requiring point of sale signage that shows health risks of tobacco use and providesWashinqton State Ouitline information. The health behaviors of people who usetobacco are strongly influenced by their understanding of the health risks ofsmoking. Those who perceive greater smoking-related health hazards are morelikely to consider quitting and to quit smoking successfully. Health warnings arestrongly associated with health knowledge.5 Research has shown that healthwarnings which communicate the adverse health effects of tobacco use are amongthe most effective at prompting smokers to quit.6 In addition, research has shownthat smokers find pictorial warnings more effective and engaging than text-onlywarnings.? This policy would require both pictorial warnings and Quitline promotion

3 7


8/43

at point of sale locations (see adjacent example from NewYork City). This strategy also provides further outreach topopulations that may not be receiving Quitline messagesin traditional ways and sends the entire community themessage that assistance to quit is available for everyone.Research has shown that utilization of cessation servicesincreases when smokers are made aware of theiravailability.8,9 Displaying this information where cigarettesare sold will ensure that smokers are informed aboutresources that are available to help them quit smoking,and increase utilization of these resources to furtherdecrease smoking prevalence in King County. We will lookto other cities that have enacted similar policies formodels when responding to legal challenges. At this time,the committee is exploring this proposed intervention and, given more informationabout the effect that this could have on business owners, this may be included in theproposal for September's vote.

Addressing Secondhand Smoke Exposure in Multi-unit HousingDevelop model lanquage for landlords and/or cities, including smoke.;free policies and leasedisclosure policies. Secondhand smoke is a class-a carcinogen.1o Even small amounts ofsecondhand smoke exposure have been shown to cause respiratory distress in people withcertain disabilities and pre-existing conditions including particularly children with pre-existing health conditions such as asthma. Studies have shown that cigarette smoke travelsthroughout a multi-unit building and that structural modifications or air-filtration systemsare not adequate to prevent smoke from traveling between units.11 The Surgeon Generalhas stated that there is no safe level of exposure to secondhand smoke. Additionally, theUS Department of Housing and Urban Development strongly encourages Public HousingAuthorities 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 andworkplaces 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 allresidents in King County, regardless of age, race, gender, or socio-economic status. A 2008PHSKC survey of multi-unit rental housing found that 1 in 5 residents report exposure todrifting smoke at least a few times a week.12 There are large inequities in the proportion ofhomes in which smoking is permitted: such homes are seven times more common amonglow income groups than more affluent ones and twice as common among African Americansand American Indians/Alaskan Natives than among whites.Given that there is such high demand for smoke-free housing, it is not surprising thatapartment management companies and condo boards are showing interest in the idea and afew 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 opportunityto work with housing providers who serve residents who are disproportionally affected bysmoking and secondhand smoke exposure to assist them in making their properties smoke-free and offering cessation resources to their residents who smoke. King County hasalready successfully piloted the project with several housing providers. A barrier to thefurther proliferation of smoke-free policies is the erroneous belief of many landlords thatsuch a policy is not legaL. The SOH, in developing model policy for landlords and cities, willcreate change by being a leader in disseminating tools for desired and effective policy.

4 8


9/43

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). 2009July 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 smokersabout the risks of smoking: findings from the International Tobacco Control CITe) FourCountry Survey. Tob Ctrl15(Suppl 3): iii19- iii25.6 Biener, L et al. (2000). Adults' response to Massachusetts anti-tobacco televisionadvertisements: 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 cigarettepackages. Am J Prev Ned 30(6):467-73.8 Farrelly, MC et al (2007). Effectiveness and cost effectiveness of television, radio and printadvertisements 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 increasingabstinence. Am J Prev Med 35(4): 386-388.10 United States Environmental Protection Agency. Respiratory Health Effects of PassiveSmokinq: Lung Cancer and Other Disorders. Washington: U.S. Environmental ProtectionAgency, Office of Research and Development, Offce of Health and EnvironmentalAssessment, 1992 (accessed 2010 June 25).11 American Society of Heating, Refrigerating and Air-Conditioning Engineers. EnvironmentalTobacco Smoke: Position Document.) Atlanta: American Society of Heating, Refrigeratingand Air-Conditioning Engineers, 2005 (accessed 2010 June 25).12 Gilmore Research Group. King County Survey of Rental Housing Residents: Compliancewith an Attitudes about Smoke-Free Rental Housing. King County, WA: August 2008.

5 9


10/43

tling CountyKing County Board of Health

Staff ReportAgenda item No: 7Briefing No: 10-B17 Date: July 15, 2010Prepared by: Natalie Lente

Subject2009 Health Care for the Homeless Network Anual Report

SummaryPer 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 HealthCare for the Homeless grant under section 330(h) of the Public Health Services Act. Themeeting proceedings ofthe BOH must reflect a review of the Health Care for the HomelessNetwork Anual Report each year.BackgroundOversight of the Health Care for the Homeless Network (HCHN) and consumer input requiredby the federal grantor is provided by a community-based advisory Planning Council withrepresentation from throughout King County. The purpose of the Health Care for the HomelessNetwork Planning Council is to provide programmatic guidance and policy direction to HCHNadministrative staff, Public Health-Seattle & King County management, and the King CountyBoard of Health. The HCHN Planng Council is not a governing body and operates in anadvisory function only.In this role, the HCHN Planning Council is responsible for the presentation of the HCHN AnualReport to the BOH which provides an evaluation of health center activities, including servicesutilization patterns, productivity, patient satisfaction, achievement of project objectives, andquality improvement.In coordination with its i 5-member Planning Council, the Health Care for the HomelessNetwork (HCHN) conducted a needs assessment in late 2008 to gather input from individualsimpacted 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 HCHNpriority actions for 2009-2014:

i 10


11/43

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 KingCounty where people ate experiencing homelessness.3. Assure the provision of services that address the increasing acuity and complexity ofhealth care problems.4. Address the need for increased access to information about health care resources and tohealth care coverage.5. Expand our awareness and focus on trauma informed care in recognition and response tothe 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 housingfirst/supportive housing model to increase housing stability for persons with histories ofchronic homelessness.The priority actions above guided much of the work of HCHN in the first year of the grantproject period and significantly contributed to the outcomes achieved by the program in 2009.2009 AccomplishmentsEnhanced Nursing Services in Supportive HousingThe Housing Health Outreach Team (HHOT) provided 912 nursing visits to 78 clients and linked46 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 inthe building. Neighborcare Health.Established an Interdisciplinary Street Outreach TeamWith funding support from the City of Seattle and United Way of King County, the new REACHoutreach 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 ClinicExpanded Case Management Services to Chemically Dependent IndividualsThe REACH team enrolled 185 chemically dependent, chronically homeless clients into casemanagement, moved 95 clients into permanent housing and 53 into transitional housing, linked93 people to inpatient CD treatment and helped 138 people access primary care. EvergreenTreatment Services

2 11


12/43

Increased Mental Health Outreach ServicesMental health providers served 435 people in Downtown Seattle, South King County and EastKing 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 andConsultation and Harborview Medical Center/Pioneer Square ClinicCoordinated Emergency Response for People Living HomelessIn 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. HCHNconvened a stakeholder group of funders, governent and health care agencies, and advocates toguide the planning process.Implemented Two Federal AR GrantsPublic Health received two federal grants to increase primary care and social work, support a siterenovation for an expansion of Medical Respite, create new exam rooms in a Public HealthCenter, purchase medical and dental equipment, and help plan for electronic medical records inPublic Health.

In 2009 HCHN maintained a diverse funding base of approximately $6.4 million annually, withsupport from:Federal- HHSIHRSA/Bureau of Primary Health Care - Health Care for the HomelessProgram 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 familiesCity of Seattle Human Services Deparment (HCHN's 2nd largest funder)United Way of King CountyKing CountyState Public Health FundingMedicaid 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 peopleseen 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 abusedisorders, skin disorders, heart problems, upper respiratory infections, musculo-skeletaldisorders, abuse-related issues, and acute health problems.In 2008, the Bureau of Primary Health Care developed required clinical performance measuresfor all federally qualified health centers. The HCHN 2009 Anual report details Public Health's

3 12


13/43

performance on eight clinical measures required by the grant.

ATTACHMENTS1. 2009 Health Care for the Homeless Network Anual Report

4 13


14/43

Health Care for the Homeless NetworkCommunity Health Services Division

2009 Annual Report

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

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

14


15/43

Table of ContentsA. Introduction.......... .............................................. .........................................................1B. 2009 Accomplishments................................................ ......................... .....................3C Program Resources (Federal, Local, Private) ............................................................ 6D. 2009 Data Summary........................................................... .................................. ...... 7Client Demographics

Health CharacteristicsPublic Health - Seattle & King County Clinical Measures for Homeless Patients

E. Death Data............... ....... ............... ........................ .... ......... ..... ...... ..... ........... ........ ... .15F. Program Updates and Expansions ... ...... .................. ..................... .......................... .17

Chief Seattle ClubHousing Health Outreach TeamMedical RespiteMental Ilness and Drug Dependency (MIDD)Pathways HomeThe REACH ProgramSecond Avenue ClinicThird Avenue CenterHCHN Services for Homeless People Provided Within Public Health

Appendices ........ ...................................................... .......... .................... ........... ........... ..25Major Service Sites............................................... .............. ....:............ ........... Appendix ACore HCHN Shelter and Homeless Site Services........................................... Appendix BPublic Health Clinical Measures for Homeless Patients ............................... Appendix CAcknowledgements...................................................... ................ .................................. 28

Questions about this report may be directed to:Natalie Lente, HCHN Manager206-263-8343, natalie.lenteckingcounty.govHealth Care for the Homeless NetworkPublic Health - Seattle & King County401 5th Avenue Suite 1000, Seattle, WA 98104/206-296-5091http://ww. kinqcountv .Qov/health/hch

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

15


16/43

. IntroductionThe Health Care for the Homeless Network (HCHN) completed its 24th year of health servicecoordination in 2009 for people living homeless and in supportive housing throughout Seattleand King County. HCHN is pleased to providethis report highlighting our work in 2009.HCHN continued to align activities with theTen- Year Plan to End Homelessness in KingCounty and the United Way Blueprint to EndChronic Homelessness. These key initiativesinfluenced the implementation of a morecollaborative and systematic approach toaddressing homelessness.BackgroundHCHN is organized through contracts withcommunity-based agencies, such ascommunity health centers, to provide services to homeless and formerly homeless individuals.HCHN providers are currently located in over 40 sites throughout King County, primarily sheltersettngs (see Appendix A). These partnerships make up the core of the network. HCHN alsoencompasses the medical, dental, and case management services provided to homeless peoplethroughout Public Health - Seattle & King County's health centers and programs.Homeless people are more likely than housed people to use the emergency department as theirregular source of care.1 Due to their lack of insurance coverage and other barriers, homelesspeople are also far less likely to access regular preventive care and cancer screenings, such asPap tests and mammograms, than those who have coverage. By providing field-basedservices, 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 accessto all aspects of health care for people living in poverty and experiencing isolation anddisplacemenI. Staff and programs recognize the importance of providing integrated carethrough interdisciplinary treatment teams that coordinate primary medical and dental care,access to a health care home, mental health treatment and substance use treatment, affordablehousing, 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~~~1

16


17/43

Priority ActionsIn 2008, HCHN worked with its 18-member community-based advisory Planning Council (seeAcknowledgements) and other stakeholders to gather input for a needs assessment fromindividuals 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 priorityactions for 2009-2014:1. Ensure the application of evidence based practices that promote human dignity, empowerparticipants, and improve health outcomes.2. Continue to provide services "where people are" including day centers, shelters, streets, andsupportive housing, working to improve access all geographic areas of King County wherepeople are experiencing homelessness.3. Assure the provision of services that address the increasing acuity and complexity of healthcare problems.4. Address the need for increased access to information about health care resources and tohealth care coverage.5. Expand our awareness and focus on trauma informed care in recognition and response tothe 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 EndHomelessness in King County including alignment with the goal of the housing first /supportive housing model to increase housing stability for persons with histories of chronichomelessness.

2i 7


18/43

B. 2009 AccomplishmentsEnhanced Nursing Services in Supportive Housing

The Housing Health Outreach Team (HHOT) provided 912 nursing visits to 78 clients andlinked 46 clients to primary care as a result of increased nursing services at Catholic HousingServices' Wintonia building to support the growing number of Sobering Center frequent usersplaced in the building. Neighborcare HealthEstablished an Interdisciplinary Street Outreach Team

With funding support from the City of Seattle and United Way, the new REACH outreachteam moved 36 clients, found living outdoors, to permanent or transitional housing. Almost1,200 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 IndividualsThe REACH team enrolled 185 chemically dependent, chronically homeless clients into casemanagement, 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 ServicesMental health providers served 435 people in downtown Seattle, south King County and eastKing County, funded through Mental Ilness and Drug Dependency (MIDD) sales taxrevenue, with an emphasis on people leaving jails and other institutions. Valley CitiesCounseling and Consultation and Harborview Medical Center/Pioneer Square Clinic

Coordinated Emergency Response for People Living HomelessIn response to the novel H1 N1 influenza and the flood threats posed by Howard HansonDam, HCHN developed a homeless response plan in preparation for both emergencies.HCHN convened a stakeholder group of funders, government and health care agencies, andadvocates to guide the planning process.

Implemented Two Federal ARRA GrantsPublic Health received two federal ARRA (American Recovery and Reinvestment Act) grantsto increase primary care and social work, support a site renovation for an expansion ofMedical Respite, create new exam rooms in a Public Health Center, purchase medical anddental equipment, and help plan for electronic medical records in Public Health.

318


19/43

In 2009 Health Care for the Homeless Network (HCHN) continued to align activities with theTen- Year Plan to End Homelessness in King County and the United Way Blueprint to EndChronic Homelessness.Linked Homeless Peopl~ to Systems of CareHCHN's outreach model locates providers where homeless people spend time and coordinatesaccess to health related services in mainstream systems.. 2,076 people to primary care services

. 829 people to mental health services

. 490 people to chemical dependencytreatment

. 2,020 people to dental services at theDowntown Public Health Dental clinic

. 2,226 households to support for Medicaidand other entitlement applications

Prevented Discharge Back to the StreetsHCHN-contracted programs target high risk, vulnerable people who are often high utilizers ofhospitals, jails, and other public institutions.

Harborview's Medical Respite program, operated by the Pioneer Square Clinic at theSalvation Army's Willam 'Booth shelter and YWCA's Angeline's Center, served 331 peopledischarged from hospitals or clinics. They placed 81 clients into ~ransitional or permanenthousing at the completion of their respite stay.The Tuberculosis (TS) program social worker assisted ten homeless TS patients to attainpermanent housing after completing TS treatment.Valley Cities Counseling and Consultation and Pioneer Square Clinic provided mental healthservices to 400 people targeting people leaving jails, hospitals and other institutions indowntown Seattle and south and east King County.

419


20/43

Provided Services to People Transitioning Out of HomelessnessHCHN supports community efforts to end homelessness through services that help peoplemaintain their housing, using proven models that employ interdisciplinary teams and fosteringcoordination between partner agencies.

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

Pathways Home moved 44 families into housing. Providers continued to work with familesfor six months after they moved into permanent housing. Neighborcare Health and ValleyCities Counseling and ConsultationThe REACH Case Management team moved 95 clients to permanent housing. Casemanagement continues to help stabilze clients as long as they require support. The StreetOutreach team moved 81 people out of encampments and into permanent or transitionalhousing or shelter. Those who required support to maintain housing were transferred to aREACH case manager.

Conducted Network-Wide Quality Improvement ActivitiesAll HCHN contracts are expected to include homeless populations in their overall qualitymanagement activities. In addition, with support from the HCHN Planning Council, the programconducts patient and provider surveys, chart reviews, and monitors extraordinary occurrenceforms related to deaths and other incidents.HCHN family nurses updated their pediatric protocols. The protocols were presented at theNational Health Care for the Homeless meeting and are now available on the National HealthCare for the Homeless website: ww.nhchc.org.Program PlanningInformed 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 fordecision making regarding HCHN service sites was completed at the end of 2009. Criteria wereestablished to assess recommended changes or expansions to services as new funding sourcesbecome available.

520


21/43

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

Chart 1Revenue Source Comparison 2005 and 2009In $3. 5 __________.__.____n__..______._____________m~______.____----.--~--.--i:.2 $3.0~ $2.5

$2.0$1.5$1.0$0.5 --$0.0

EI 2009EI 2005

Local funding to HCHN increasedsignificantly beginning in 2007,whereas federal funds have remainedfairly leveL. In 2009, local fundscomprised 38% of the budget($2,452,676), up from 22% in 2005($986,625). Local funders include theCity of Seattle (HCHN's 2nd largestfunder), United Way of King County,King County Veterans and HumanServices (VHS) Levy, and MentalIllness Drug Dependency (MIDD)sales tax revenue. The increase inlocal funds has improved the ability toleverage additional MedicaidAdministrative Match for eligibleservices.

Federal Local Medicaid Private & FederalMatch Other ARRA

Chart 2HCHN Local Revenue Sources

\/S LeVKing County 17%Expens eFunds

1%State PH4%

MedicaidMatch15%

DCHS3%

United Way7%

6 21


22/43

D. 2009 Data SummaryThis section highlights services provided by HCHN-contracted providers in 2009.3 Services wereprovided by approximately 118 full time equivalent staff. Approximately half of the providerswere medical staff, including nurses and nurse practitioners, physicians and physicianassistants. The remaining providers were mental health counselors, substance abusecounselors, case managers, outreach and engagement workers, and Medicaid enrollmentspecialists.Number of Clients Served and Visits Providedby HCHN Chart 3Total HCHN Visits 2005-09

60,000 .. .-------.---.-~-.-.----.-.----..--__. _____50,00040,00030,00020,00010,000

o

As ilustrated in Chart 3, HCHN contractorsprovided 52,143 visits with clients in 2009, a 22%increase since 2005. Similarly, HCHNcontractors served 8,830 individuals in 2009, an8% increase since 2005.These increases likely represent expandedHCHN services due to new local funds.

Chart 4Clients Seen at HCHN and PublicHealth Sites 2009

2005 2006 2007 2008 2009

HCHNSites40%

Public Health - Seattle & King County's HealthCenters provided 50,646 visits to 13,076 .homeless individuals in 2009, representing 60% ofclients served.PublicHealth60%

Household Status of HCHN ClientsSingle adult males make up the largestportion (64%) of individuals served byhousehold type, similar to datacollected by Safe Harbors HomelessManagement Information System in2008.

Young Adult(18 - 24 yrs)9%

In total, 528 familes were servedrepresenting 1,462 adults and children. Female19%

Cha rt 5Household Status of HCHN ClientsUnknown

8% Family17%

Single AdultMale45%

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 tounduplicate client data.

'-;l~;4f;,ll;,~ii:&~i:J~:01~;E't.:~tt.t~~17

22


23/43

Age and Gender of HCHN ClientsAs shown in Chart 6, over the past 5 years, HCHN saw a 23% increase in the number of clientsage 40 and over, whereas those 39 and under have remained fairly stable.The aging trend in the homelesspopulation has been identified in othercities across the country.4 Althoughthe barriers for elderly persons whoare homeless are similar to those ofyounger homeless persons, they maybe more diffcult to overcome whencompounded by additional challengesassociated with aging, such as chronicmedical conditions, frailty, poormobility, and loss of hearing oreyesight.

3,5003,002,5002,001,5001,0050

o

Olrt 6Increase in Older aient, ~ 2005~95,SOO5,0004,5004,000---f;3,5003,000

~_::=::92005 2006 2007 2008 2009

Chart 7Age and Gender, HC 20

0-11 12-17 18-24 25-39 40-54 55- 65+mmale (60%) Elfemale (40%)

Men served by HCHN in 2009were older on average (46years old) compared to women(40 years old).Two hundred and ten HCHNclients were unattached youth,meaning they were less than 18years old and not living withtheir parents. Nine percent(790 clients) were young adultsbetween 18 and 24 years old,living on their own.

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

;E!;;~trtraft~jlf~~~1~71~:Xj~rttrF~j8

23


24/43

Race and Ethnicity of HCHN ClientsPeople of color represented a disproportionate percentage of HCHN clients in 2009 compared tothe population of King County (46% vs. 24%). As shown in Chart 8, the race distribution ofHCHN clients was similar to race distribution from other data sources in King County thatcollected 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 ManagementInformation System (HMIS).Although 6% of individuals served by HCHN in 2009 were of unknown race, the majority of thoseindividuals were of Hispanic ethnicity with no other information. In total, 14% of HCHN clientswere Hispanic.

Chart 82009 HCHN Race Compared toKing County Homeless and Total King County Population

100% I2 Whitem More than one raceand othero American Indian/Alaska Natil.o Black/AfrcanAmericanli Asian/Pacific IslanderlI Unknown

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

80%60%40%

20%

0% HCHN KC Shelters KC HMIS King County

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

Geographic Location of HCHN Services

924


25/43

History and Length of Homelessness of HCHN ClientsHomeless background information was available on about half the HCHN clients served. Ofthose who reported this information, the number of clients who were homeless more than threeyears increased steadily from 14% to 20% between 2005 and 2009.The increase in length of homeiessness may be related to the effectiveness of HCHN providersin targeting the chronically homeless population and program expansions such as the REACHcase management and outreach teams. Of the people who were homeless for more than threeyears, almost all (93%) were single adults.Fairly consistent over the past five years, 43% of HCHN unattached youth and adults had beenhomeless three or more times. Also consistent over time, 11 % of HCHN clients in familes werehomeless three or more times.Health Problems of HCHN ClientsNumerous studies have documented that homeless people experience many health problems atrates higher than housed people. Among homeless people nationally, nearly 40% have sometype of chronic health condition. Homeless people are more likely to use the emergencydepartment as their regular source of care.5 Almost one out of nine homeless childrenexperience one or more asthma-related health conditions. In comparison, less than one in 15middle-class children experience asthma-related health conditions.6Data 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 amongthe homeless shelter and day program population served by HCHN in recent years.Skin issues were the tophealth concerns of HCHNclients 12 to 54 years old in2009. Typical skinconditions in in homelessadults include diabetic andvascular ulcers,abscesses, wounds,infections (includinginfections resulting fromitching related to bedbugbites), lice, and scabies.

Chart 9Selected Chronic Health Conditions,HCHN 2005-09

14%12%10%8%6%4%2%0%

---------.------~-- ------.-------- -- Hypertension.------------- --------------------- __ Diabetes____~___.___._______________________.._________._m'._._....._ -- Asthma_d.~..~..u . Atd At

2005 2006 2007 2008 2009Skin conditions were thesecond most common5 Homelessness and Health: The Effect of the Course of Homelessness on Health Status and Health Care Use, American Journal of PublicHealth, March 2007, VoL. 97, No.3.6 National Center on Family Homelessness http://ww.homelesschildrenamerica.org/repoa-child-wellbeing_health.php

.~K;;:;110

25


26/43

concern for clients under 12 years old. Typical skin conditions in this age group includediaper rash, impetigo, lice, contact dermatitis, and eczema.The top health concern of those 55 and over was cardiovascular disease. Cardiovasculardiseases include hypertension, high cholesterol, congestive heart failure, and stroke.As shown in Chart 9, since 2005, the percentage of HCHN clients with hypertensionincreased 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 musculoskeletalconditions 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. Typicalrespiratory conditions in this age group include colds, influenza, shortness of breath,asthma, chronic obstructive pulmonary disease, pneumonia, and tuberculosis. The tophealth concerns among children under 12 was respiratory conditions. Typical respiratoryconditions in this age group would include colds, influenza, asthma, pneumonia, and sorethroats.

Chart 10Health Problem Prevalence Among HCHN Adults, 2009

SkinMusculoskeletalRespiratoryCardiovascularGastrointestinalEndocrineGenitourinaryNutritionNeurological

sfemale limale0% 10% 20% 30% 40% 50%

1126


27/43

Mental Health and Substance AbuseThe number of homeless people with mental health problems in King County is significant, withabout half of all existing HCHN patients having some type of mental health and/or substanceabuse disorder. In the 2008 HCHN online needs assessment survey, homeless serviceproviders 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 topconcern of 12-24 year olds.Thirt-two percent of all 18-24year olds had mental healthissues addressed during a visitin 2009. The proportion ofyoung people with mentalhealth concerns jumped from8% in under 12 year olds, to21% in youth 12-17 years old.

Chart 11Mental Health and Substnce Abuse PrevalenceAmong HCHN Adults 2009

El male 0 female0% 10% 20% 30% 40% 50%

MentalHealth

SubstanceRelatedSubstance abuse concernswere addressed among 30% ofHCHN adults in 2009. Substance related issues were the most prevalent among men age 55and over. Thirt-five percent of men in this age group had a substance-related issue addressedin a visit.

In the 2008 provider survey conducted by HCHN inits strategic planning process, respondentsidentified the need for more integrated carebetween service systems for people duallydiagnosed with both mental health and substanceabuse problems. Providers concurred that clientswho need the services of both systems arefrequently "bounced between them" and may not, inthe end, be served by either system. Theysuggested continued training for health care providers regarding appropriate interventions forparticipants with substance abuse issues and mental health issues including more access tomental health supports.Providers reported that comprehensive case management is a necessity for any client that haschronic mental health, substance abuse, or language diffculties and that without it, manyindividuals will continue to fall through the cracks.

~:~~gjff~fftK4i~lm;w~%Z!\lt?nt~12

27


28/43

Spotlight on VeteransDue to increased community and funder interest in homeless veterans, a few data snapshots arepresented here about veterans served by HCHN.Miltary veteran status was not available for all HCHN clients. Providers report that clients aresometimes 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 in2009 were miltary veterans. The number of veterans served by HCHN providers has increasedeach 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 notablyolder (average age of 53 years) comparedto all HCHN adult clients (43 years old).According to census data, veterans who arehomeless are younger than the generalveteran population of King County.? IraqWar era and younger veterans are overrepresented among homeless veterans.8

7 American Community Survey 2006 and 20078 Veterans and Human Services Levy Outcome Evaluation of Strategy One, Attachment A, King County Department of of Community and HumanServices

1328


29/43

Public Health - Seattle & King CountyClinical Measures for Homeless PatientsIn 2008, the Bureau of Primary Health Care developed required clinical performance measuresfor all federally qualified health centers. Public Health - Seattle & King County clinics areestablished as a federal health center as a part of the scope of services for our homeless grantunder section 330(h) of the Public Health Services Act.Below are two of the HRSA required measures for the 2010-2014 project-period. (The remainingtarget goals and outcomes for 2009 are included in Appendix C of this report).

Diabetes inhomeless primarycare patients

Cardiovascular:Hypertension inhomeless primarycare patients

Increase the % of adultpatients with type 1 or 2diabetes who are beingtest and whose mostrecent HbA 1 cis .s9%.Baseline:72%Goal: 80%Increase the % of adulthomeless patients withdiagnosed hypertensionwhose most recentblood pressure was lessthan 140/90 (adequatecontrol): Baseline:47%Goal: 55%

72%Total number of patients: 72Total number of patients inrandom sample: 72Number of clients with HgA 1 cunder 9%: 52

47%Total number of patients: 116Total number of patients inrandom sample reviewed: 116Number of clients with controlledblood pressure: 33

59%Total number of patients: 78Total number of patients in randomsample: 78Number of clients v.ith HgA 1 cunder 9%: 45

60%Total number of patients: 171Total number of patients in randomsample reviewed: 70Number of clients with controlledblood pressure: 42

Testing for hemoglobin A1c (HbA1c) is one of the best ways to assess whether one's bloodglucose 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 bloodglucose from 2008 wil be analyzed in 2010. There may have been fewer tests done; manydiabetic patients living homeless also have mental health issues which can become competingvisit priorities. Although taking insulin can be effective for blood glucose control, it requiresrefrigeration 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 in2009 at Public Health - Seattle & King County clinics to properly assign patients the diagnosis ofhypertension and to assure they were correctly entered into our disease registry. Strategies wereimplemented 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 healthoutcomes and measures of health. As patients rotate through our expanded outreach and casemanagement services, the overall goal is to identify a medical home and seek care more often,which should result in improved outcomes.

14 29


30/43

E. Death DataHCHN annually reviews death information on all individuals who died in King County and whowere 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 oftheir death. This is the lowest number of deaths reported by the KCME since this data was firstcollected 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, theaverage age of death in 2009 was 48 years old.Homelessness May Increase Suicide, Homicide, and FatalAccident RiskHCHN reviewed all deaths for which the KCME assumedjurisdiction in order to determine if living homeless may make aperson more likely to die by suicide, homicide, or accident. Theinformation below compares homeless deaths to other deaths inKing County from 2004 through 2008. (Data is not yet availablefor 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 amongpeople living homeless. For a rough comparison, only 1 % of the King County population isestimated 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 oftheir death.Another notable difference was in deaths where serious doubt existed as to whether the injuryoccurred with intent or as a result of an accident.12 In these cases, the KCME designates themanner 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 morediffcult 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 diedsuddenly 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 for2006. 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 AnnualReport. Available at: hlt:llww.kingcounty.gov/healthservices/health/examiner.aspx.

WiJir~~'&~w.&'t015

30


31/43

r----~------.----.---.--------.----------~--.---.--..-.-.--.-----.-----------------.-----..-.-.-------.-.--Profile of Deaths Between 2004 and 2009 IiIiiIiI

The leading single cause of homeless deaths between 2004 and 2009 was acute intoxication(29% of deaths). In 2009, the number of deaths due to acute intoxication decreased (16 deathscompared to the high of 30 in 2005).Suicide comprised 8% of deaths in 2009, the highest year for suicides (11 deaths compared tothe low of 3 in 2007). However, homeless individuals experienced the lowest number ofhomicides 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 relatedaccidents totaled 15% of all deaths.13 These other causes specifically included:

. Killed by cars or train (22 deaths) . Carbon monoxide-related such asEnvironmental exposure (9)

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

Of the 526 homeless deaths between 2004 and 2009, the majority (85%) were men. Theaverage 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 thatled to the deaths between 2004and 2009 occurred in Seattle(73%). Homeless deaths occurredin other regions as well: 81 deaths(15%) in south King County, 22deaths (4%) in east King County,8 deaths (2%) in north KingCounty. Incident locations outsideKing County included 15 deaths(3%). In addition, the incidents in17 deaths (3%) occurred inunknown locations.14

Chart 12Number of Homeless Deaths,King County Medical Examiners Offce 2004-09

15010050

o

110

2004 2005 2006 2007 2008 2009

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.

1631


32/43

F. Program Updates and ExpansionsHCHN Contracted ServicesThis section highlights outcomes of selected HCHN programs. The activities described here arenewer and focus on particular sub-populations or emphasize the more recent incorporation of anoutcome focus on housing linkages and stabilzation.Chief Seattle ClubSeatte Indian Health Board (SIHB) provides nursingservices at Chief Seattle Club, a site in Pioneer Squareserving predominately urban Indians. Services wereexpanded in 2009 to assist clients with chronic and acuteilnesses. Also new in 2009, the nurse can access theSIHB electronic medical record system for improved carecoordination, the Emergency Services Patrol van (ESP)is available to take clients to appointments, and arefrigerator was added which makes TB skin testing andvaccine provision, such as H1 N1 and seasonal flu,possible. The nurse also coordinates the care ofchemically dependent clients with a REACH casemanager, newly sited at Chief Seattle Club.Housing Health Outreach TeamThe Housing Health Outreach Team (HHOT), formed in 2007, is an interdisciplinary team ofmedical, mental health, and chemical dependency providers sited in 10 permanent supportivehousing buildings. Services are provided by Neighborcare Health and Evergreen TreatmentServices.The team served 587 formerly homeless residentsliving in ten buildings in downtown Seattle in 2009.Of all clients, 206 (35%) were linked to primaryhealth care services and 385 clients (66%) linkedwith mental health, chemical dependency, or dentalservices.The HHOT team also conducted several clinics for flushots, as well as foot care clinics in several of thedowntown buildings. These activities have proven tobe effective ways to connect individuals withproviders from multiple disciplines on the team.Clients newly engaged through these clinics not onlyconnected with HHOT nursing or medical services,but met with HHOT mental health and chemical dependency providers as well.

1732


33/43

Medical RespiteHCHN contracts with Harborview's Pioneer Square Clinic to operate the Respite program for upto 22 acutely ill homeless individuals at any time. For 15 years, the clinic has provided this careto 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 WillamBooth shelter, and to women at the YWCA's Angeline's shelter. The program providesrecuperative care, linkage to primary care, mental health and chemical dependency casemanagement, and discharge planning.The Respite program served 331 homelessindividuals in 2009.15 Sixt-six percent of the clientswere chronically homeless and almost 80% hadmental health and/or substance abuse problems.The average length of stay in a respite bed was 18days, a short period of time to accomplish goals setout by the program.The respite program placed 42 people in permanenthousing and 40 people in transitional housing in2009, which was the highest number of housingplacements in the history of the program.15 As reported for the HUD grant year February 1. 2009 - January 31, 2010.

JI:r~l:~18

33


34/43

Mental Ilness and Drug Dependency (MIDD) Funded Behavioral Health ServicesHCHN received new funding from the King County Mental Health, Chemical Abuse andDependency Services Division (MHCADSD) Mental Illness and Drug Dependency Action Plan.These funds provide mental health outreach services in east and south King County anddowntown Seattle. Through HCHN's contractors, Valley Cities Counseling & Consultation andPioneer Square Clinic, services are designed to stabilze people with mental illness and chemicaldependency, diverting them from jails and emergency rooms by linking them to ongoingservices.For Seattle, the expanded mental health capacity was situated in two homeless service sitesdowntown, 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 provideservices to clients referred by the King County Jail release planners, REACH Casemanagement, and the shelter sites where they are located.Similarly, services outside of Seattle prioritize clients of shelters and day programs that lackbehavioral health services and have significant numbers of clients with unaddressed mentalhealth or substance abuse conditions who are involved with hospitals, jails, and/or other crisisfacilities.Pathways HomeThe Pathways Home Program (PWH), also known as Medical Case Management for Children,was developed in 1997 to promote housing stabilty for homeless families experiencing multipleserious barriers. In 2009, Valley Cities Counseling & Consultation and Neighborcare Healthprovided mental health, chemical dependency, nursing care, social work, and housingassistance to familes throughout King County.Until the family ispermanently housed(and for six monthsafterwards), the multi-disciplinary teamprovides continuity incase management andtherapeutic servicesregardless of where thefamily is residing or howmany times they move.During the past year,99 familes were served,with 47 new familesentering during the year.Fort-eight familes moved one level up the continuum of housing (56%). Thirt-five of thosefamilies moved into permanent housing (41%) and nine moved into transitional housing. All

1934


35/43

families entering the program during the year (100%) were evaluated for health care coverageand linkage to a primary care provider. Seventy-eight families (79%) met at least one goal oftheir service plan.REACH Outreach Team and Case Management ProgramIn 2009 REACH case management services were significantly expanded. Additional fundingfrom the Veterans and Human Services Levy, the City of Seattle Human Services Division, andUnited Way of King County supported increased case management and contributed to thecreation of a new street outreach team.

Outreach Team: In 2009 the Outreach team made contact with over 450 people living outdoorsand referred 172 people to services. Of those engaged, 91 people entered a shelter or housingand 110 people engaged with a REACH nurse. Experienced outreach workers were surprisedby the high numbers of people with serious, untreated health conditions. They found people tobe very receptive to services, resulting in high levels of engagement and success in linking themto health care, treatment, as well as housing.Case ManagementTeam: New funds resulted in expanding the scope of REACH services to acase load of 320 people, 185 of them new in 2009. SerVices were made available to the entireSeattle 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


36/43

expanded to included homeless people using illegal drugs resulting in program collaborations atsites including the Chief Seattle Club, the Needle Exchange, the Medical Respite program, theHigh Utilizer Group, and Angeline's Center. In 2009, 209 case management clients were linkedto chemical dependency services, 156 clients moved to an improved housing situation with 95moving to permanent housing, and 138 people engaged in ongoing primary care services.Second Avenue ClinicThe Second Avenue Clinic has provided health services side by side with Public Health's NeedleExchange 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 DowntownHealth Center in Belltown.The clinic focus is prevention of skin wounds that require hospitalization. Two providers, aPhysician's Assistant and a Nurse Practitioner, alternate on-site each afternoon, providingwound care treatment for abscesses, cellulitis, ulcers, and infections. Care for other healthissues is available and clients can see the same providers at Pioneer Square Clinic. The vastmajority of clients were seen for wound care. Other common conditions included upperrespiratory infections, musculoskeletal disorders, and peripheral vascular disease.Third Avenue CenterThe Third Avenue Center (TAG), a health care clinic operated by Harborview Medical Center'sPioneer Square Clinic, opened in 2004 to provide walk-in specialty health services five days aweek. TAC offers management of acute and chronic ilness, well adult exams, women's healthcare, family planning, diagnostic testing, podiatry, and mental health services includingpsychiatric services. The clinic primarily serves homeless adults and individuals without healthinsurance. People with Medicare and Medicaid are eligible for services and sliding scale feesare available.

2136


37/43

In 2009, the Third Avenue Center (TAC) served 1,121 patients and provided an average of3.1 visits per patient. Fift percent of T AC clients were women, which exceeds theproportion of women in the King County homeless population overall (25%), and reflectssuccess in reaching out to women.

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

HCHN Services Provided Within Public Health for Homeless PeopleOral HealthSince 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 PrimaryHealth Care. In addition to self-referred patients, the clinic maintains partnerships with agenciesproviding supportive services to currently and formerly homeless individuals. Case managers atpartner agencies refer and support clients in keeping their appointments and completing theirdental treatment plans.In 2009, 79% of the patients(comprising 76% of the total visits) atthe Downtown Public Health DentalClinic were individuals who werehomeless. As a result of the grantimplementation, the number ofhomeless users at Downtown PublicHealth has more than tripled since2005. Of homeless patients receivingperiodic or comprehensive examsbetween July 1, 2008 and December31, 2008, 28% completed treatmentwithin 12 months.

Chart 13: 2009 Downtown Public HealtDental Patients (n=2,020)

Non-HomelessPatients21%

HomelessPatients79%

Health and Safety Project: Communicable Disease and Health EducationA Public Health nurse on the HCHN team is dedicated to assisting homeless service agencies toreduce risks associated with communicable disease. In 2009, she conducted 25 health andsafety 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 ReserveCorp, HCHN delivered over 2,400 doses of H1 N1 and seasonal flu vaccine to people livinghomeless throughout King County.

2237


38/43

Enhanced Tuberculosis (TB) ServicesTB cases among the homeless have beendeclining since the TB outbreak in thehomeless community in Seattle in 2002-2003. See chart 14.

Chart 14Homeless TB Cases in King County

For the past five years, the HCHN TBprevention nurse has provided technicalassistance to homeless service agencies.In that time, agencies have instituted TBprevention policies that include annualrisk assessments, staff TB screening,increased awareness among staff throughannual staff TB trainings and new stafforientation, bed maps, education ofclients, and improved attention toventilation. In 2009, 250 staff in these agencies received TB training. In addition, HCHN hassupported a social worker in the TB Control Program to provide case management to peoplewith TB who are homeless, helping them get into permanent housing by the time they completeTB treatment. Ten of those clients retained stable housing six months after completingtreatment.

40~ 35: 30~ 25~ 20., 15E 10:iz 5

o2002 2003 2004 2005 2006 2007 2008 2009

2338


39/43

The TB and Homelessness Coalition, a partnership between HCHN, the TB ControlProgram, homeless services agencies, and funders, held three meetings in 2009 in theirwork to prevent the spread of TB in the homeless community.Emergency Preparedness for Homeless PeopleIn order to address the potential H1 N1 influenza epidemic and possible flooding in southKing County, HCHN and King County Emergency Preparedness convened a stakeholdergroup of agencies serving homeless people, funders, local and county governments, healthcare agencies, and advocates.The group prepared a community-wideplan for coping with an epidemic, suchas H1 N1. The plan is multifaceted andincludes a surveillance system forinfluenza-like ilness (Ill) at homelesssites, a plan to isolate and care forpeople with ill, the stockpilng ofsupplies, a detailed communicationplan, and an antiviral distributionsystem. A cornerstone of thepreparedness plan is the prevention ofinfluenza through health education,emphasizing protective behaviors, andvaccination.The stakeholder group also examinedthe potential impact of flooding from the Howard Hanson Dam. Although the dam did notflood in 2009, the groundwork was laid for assisting homeless individuals when a flood isimminent, and for developing an adequate response plan during and after the flood. Thisinformation was made available to local and regional jurisdictions to guide planning.

~~rir~~J:t~t~~i~i*~t~qjfj24

39


40/43

Appendix A. HCHN Major Service Sites in 2009Single 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 BeginningsHousing Services - CHS) . Providence Hospitality House Third Avenue Center (at YWCA Opportunity . Sacred HeartPlace) . South King County Multi-Service Center Willam Booth Center (Salvation Army) sites

Union Gospel Mission Family Shelter YWCA East Fir Street Shelter YWCA family sites countywideHousing Health Outreach Team (HHOT)Sites Frye Apartments(CHS) The Gatewood (Plymouth Housing GroupPHG) Kerner-Scott House (DESC) 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 UWAdolescent Medicine Clinic) Y outhCare Orion Center

Certain visits also take place in the client'shome (once housed), streets, encampments,and other sites.

2540


41/43

Appendix B. Core HCHN Shelter and Homeless Site ServicesPrograms for Families Valley Cities Counseling & Consultation manages the Familes in Shelters programsproviding mental health and chemical dependency services to families who are enduringhomelessness in Seattle and in South King County. Carolyn Downs Family Medical Center - Homeless Team provides on-site nursingservices to women and familes who reside at shelters/transitional housing sites in CentralSeattle. Odessa Brown Children's Clinic provides on-site primary health care to children whoattend First Place School and Wellspring Family Services Early Learning Center (formerlyMorningsong Day Care) in Seattle HealthPoint provides on-site nursing services to women and familes who reside in sheltersand transitional housing sites in North, East and South King County. Neighborcare Health/45th Street Clinic provides on-site nursing and mental health servicesto 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 adultsaged 12-23 in the Capitol Hil neighborhood of Seattle.Programs for Single Adults The Bridges Program (Valley Cities Counseling & Consultation) provides mental healthoutreach services to homeless sites in North, East and South King County. Pioneer Square Clinic (Harborview Medical Center) provides mental health and nursingservices to homeless adults in shelters and transitional housing sites in downtown Seattle HealthPoint provides nursing services for formerly homeless adults living in South CountyHousing First units managed by Sound Mental Health (SMH) and King County Housing

Authority. Residents are referred to housing from the SMH Projects for Assistance inTransition from Homelessness (PATH) program. Medical case management services arealso provided to clients of the Public Health - Seattle & King County South King CountyMobile Medical Van.

2641


42/43

Appendix C. PHSKC Clinical Measures for Homeless PatientsI/:.C::.\'d.",:,/'.:,.Diabetes:

Diabetes inhomeless primarycare patients

Cardiovascular:Hypertension inhomeless primarycare patients

Cancer:Pap testing forhomeless women

Prenatal andPerinatal Health:Birth weight forinfants of home-less primary carepatientsPrenatal andPerinatal Health:Early prenatalcare for homelesspregnant primarycare patientsChild Health:Childhoodimmunizations forhomeless childrenin primary careBehavioralHealth:

Oral Health:

" '0~~;.t)tfgA-t+~~fiEitR_Rr~,;~lr:t~~~~iriUif~

.... .,.: ..ZUUlS .. .:, :'.' :.:.: .~.-,..-:~ ,- ,.-c.-\H .... . .,.' C c' .Increase the % of adult pa-tients with type 1 or 2 diabe-tes who are being test andwhose most recent HbA 1 c is2.9%. Baseline:72%Goal: 80%Increase the % of adulthomeless patients withdiagnosed hypertensionwhose most recent bloodpressure was less than140/90 (adequate control):Baseline:47% Goal: 55%Increase the % of homelesswomen ages 21-64 (24-64 in2009) who have a pap testduring the same year or thetwo previous years.Baseline:70% Goal: 75%Among homeless patients,increase the % of birthweights of more than 2500grams to prenatal patients.Baseline:90%Goal: 92%Increase the % of womenwho receive prenatal careand initiate care with our or-ganization who start care inthe first trimester.Baseline: 53%Goal: 75%% of 2 year old homelesschildren who are up to dateon immunizations.Baseline: 78%Goal: 80%

% of homeless chronicinebriates served by REACHcase management team whoengage in substance abusetreatment. Goal: 55%% of homeless dentalpatients at Downtown PublicHealth with a comprehensiveoral exam who have com-pleted their treatment planswithin a 12 month period.Goal: 35%

72%Total number of patients: 72Total number of patients inrandom sample: 72Number of clients with HgA 1 cunder 9%: 5247%Total number of patients: 116Total number of patients inrandom sample reviewed: 70Number of clients with controlledblood pressure: 3370%Total number of patients: 1672Total number of patients inrandom sample reviewed: 70Number of clients tested: 4990%Total number of patients: 11Total number of patients inrandom sample reviewed: 11Number of clients with infants withbirth weights more than 2500Qrams: 1053%Total number of patients: 15Total number of patients inrandom sample reviewed: 15Number of clients with receivingfirst trimester prenatal care: 878%Total number of patients: 91Total number of patients inrandom sample reviewed: 91Number of children up to date onimmunizations: 7150%N=132

28%N=100 (chart review sample)

27

IT.,.:I .', ..\) i." '.. .,..,..i(:/Fi ....i59%Total number of patients: 78Total number of patients inrandom sample: 78Number of clients with HgA 1 cunder 9%: 4560%Total number of patients: 171Total number of patients inrandom sample reviewed: 70Number of clients with con-trolled blood pressure: 4263%Total number of patients: 1043Total number of patients inrandom sample reviewed: 70Number of clients tested: 4442%Total number of patients: 7Total number of patients inrandom sample reviewed: 7Number of clients with infantswith birth weights more than2500 orams: 347%Total number of patients: 17Total number of patients inrandom sample reviewed: 17Number of clients with receivingfirst trimester prenatal care: 877%Total number of patients: 94Total number of patients inrandom sample reviewed: 94Number of children up to dateon immunizations: 7371%N=145

32%N=1249

42


43/43

AcknowledgementsContract Partners Country Doctor Community Health Centers HealthPoint (formerly Community HealthCenters of King County) Evergreen Treatment Services Odessa Brown Children's Clinic Pioneer Square Clinic - Harborview MedicalCenter Neighborcare Health (formerly Puget SoundNeighborhood Health Centers) Seattle Indian Health Board University of Washington AdolescentMedicine Valley Cities Counseling & Consultation Salvation Army Willam Booth Center YWCA of Seatte-King-Snohomish CountyFunders City of Seattle Human Services Department King County Department of Community &Human Services King County Veterans and Human ServicesLevy King County Mental Ilness and DrugDependency Sales Tax United Way of King County U.S. Department of Health & HumanServices, HRSA, Bureau of Primary HealthCare 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 Robert Clewis Center/Public Health HIV/AIDSProgram King County Medical Examiner Assessment, Policy Development andEvaluation Unit Emergency Preparedness Public Health Centers, Community HealthServices

2009 HCHN Planning Council MembersCarole Antoncich, Homeless HousingCoordinator, King County Department ofCommunity and Human ServicesMaureen Brown, MD, Swedish Family PracticeResidency Program, Downtown Publ.ic HealthCenterLeticia Colston, MSWMark Dalton, Administrator, Washington StateDepartment of Social and Health Services,Bellown Community Service OffceJerry DeGrieck, Public Health Policy Manager,City of Seattle Human Services DepartmentSinan Demirel, Executive Director, Rising Outof the ShadowsCharissa Fotinos, MD, Medical Director,Public Health - Seattle & King CountyGreg Francis, Consumer RepresentativeMJ Kiser, Program Director, Compass CenterEd Dwyer O'Connor, Clinic Practice Manager,Pioneer Square Clinic Harborview MedicalCenterlinda Rasmussen, Regional Director, SouthKing County, YWCA of Seattle, King County &Snohomish CountyEva Ruiz, Community MemberSheila Sebron, Consumer RepresentativeSusan Rogel, Director of Homeless Services,Y outhcare

Photo Credits Neighborcare Health Evergreen Treatment Services REACHprogram Public Health - Seattle & King County

Date post:	29-May-2018
Category:	Documents
Upload:	bk-ainsworth
View:	213 times
Download:	0 times

Kings county .Washington, plan to ban e-cigarettes

Documents