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Needs Assessment of Fulton County Homeless Shelters March 8, 2004 Lenhardt & Colton, LLC Needs Assessment of Fulton County Homeless Shelters March 8, 2004 Lenhardt & Colton, LLC

Infrastructure Issue. WHAT is a Homeless Shelter? The state must be able to define Infrastructure Issue. WHAT is a Homeless Shelter? The state must be able to define the institutional target of TB control efforts. l The definition must be based on objective criteria rather than on shelter services or on shelter funding sources. l – An issue with multi-program facilities. l There is an clear distinction between “overnight” and “extended stay” shelters. (pp 19 -26) 2004 Lenhardt & Colton, LLC 2 March 8, 2004

Infrastructure Issues. Inventory of Homeless Shelters The state must be able to identify (I. Infrastructure Issues. Inventory of Homeless Shelters The state must be able to identify (I. e. , list) the institutional targets of TB control efforts. l Today, there are many different “lists”. l – DHR has a list of homeless shelters. – Mercy Care Services has a different list. – United Way of Metropolitan Atlanta has yet another list. – HUD includes shelters for “battered spouses” and “runaway children” in its list. 2004 Lenhardt & Colton, LLC 3 March 8, 2004

Problem Statement #1 Risks of TB Not Acknowledged l Shelters believe that the risks Problem Statement #1 Risks of TB Not Acknowledged l Shelters believe that the risks presented by TB are not as great as other risks facing the homeless. l Not that the control of TB is unimportant- just not as important as other shelter issues. (pp 67 -70) 2004 Lenhardt & Colton, LLC 4 March 8, 2004

Problem Statement #1 Risks vs. Shelter Resources l “The lack of immediacy appears to Problem Statement #1 Risks vs. Shelter Resources l “The lack of immediacy appears to be a greater barrier to 2004 Lenhardt & Colton, LLC 5 March 8, 2004

Problem Statement #2 Non-Custodial Institutions Homeless shelters are non-custodial institutions. l Even if a Problem Statement #2 Non-Custodial Institutions Homeless shelters are non-custodial institutions. l Even if a homeless individual is convinced to obtain a TB test through a shelter-based screening process, there is no ability within a shelter to ensure that the resident will l – Return to have the test “read” – Obtain and/or complete treatment if active TB diagnosed. (pp 45 -51, 52 -53, 60 -61) 2004 Lenhardt & Colton, LLC 6 March 8, 2004

Problem Statement #2 Insights from Mercy Care Services l For the grant cycle 4/1/02 Problem Statement #2 Insights from Mercy Care Services l For the grant cycle 4/1/02 through 3/31/03, Saint Josephs placed 994 PPD tests and had 854 of those clients return to have the test read, a ratio of 85. 9%. l “The consensus was that the majority of individuals not returning to have their PPD skin test read were sheltered at overnight emergency shelters. ” l “Conversely, individuals sheltered in transitional or other extended-stay shelters were more likely to have their PPD skin tests read. ” 2004 Lenhardt & Colton, LLC 7 March 8, 2004

Problem Statement #3 Absence of Engineering Controls Engineering TB controls such as ventilation systems Problem Statement #3 Absence of Engineering Controls Engineering TB controls such as ventilation systems and/or HEPA filters are effective at reducing the incidence of TB. l Homeless shelters do not have the capability to install engineering controls. l – the staff, – the expertise, – the resources Once installed, shelters do not have the capability to engage in the routine maintenance and testing necessary to keep those engineering controls effective. l Shelters have no incentive to procure or develop staff, expertise, and resources. l (pp 38 -44) 2004 Lenhardt & Colton, LLC 8 March 8, 2004

Problem Statement #3 Engineering Controls @Site Visits l None of the six Fulton County Problem Statement #3 Engineering Controls @Site Visits l None of the six Fulton County shelters visited operate special ventilation systems designed with TB control in mind. • External ventilation generally occurs for rooms in which congregate activities occur. • No routine determination is made by shelters of the number of air changes per hour (ACH) within the shelter or the specific rooms by that external ventilation. • No routine determination is made by shelters of the impact of peak shelter usage on the air quality within congregate rooms. • No duct testing occurs to determine that ducts operate with appropriate negative pressure and/or without leakage. • No site visit shelters use HEPA filters as either a primary or supplemental engineering control. 2004 Lenhardt & Colton, LLC 9 March 8, 2004

Problem statement #4 Lack of TB Experience Homeless shelters lack the experience with TB Problem statement #4 Lack of TB Experience Homeless shelters lack the experience with TB upon which to base the development of effective TB control protocols. l Shelters lack the ability to self-define what would constitute an effective comprehensive TB control program. l (pp 51 -54, 54 -58) 2004 Lenhardt & Colton, LLC 10 March 8, 2004

Problem Statement #4 Lack of TB Control Protocols l Of the 23 shelters providing Problem Statement #4 Lack of TB Control Protocols l Of the 23 shelters providing responses to the written survey, four (4) indicated that they were “actively implementing a TB control procedure. ” Of those four shelters, however, none (0) had committed their TB control procedures to writing. l The results of the written survey indicated that three (3) shelters responded that the shelter had, “in general, ” committed to writing “the steps it takes to control the exposure of its residents or workers to tuberculosis. ” None (0) of these three shelters, however, were the same shelters that indicated that they were actively implementing a TB control procedure. More importantly, none (0) of the three shelters could produce a copy of the written procedures when requested. 2004 Lenhardt & Colton, LLC 11 March 8, 2004

Problem Statement #4 Shelter Experience with Testing A sufficient number of shelters require such Problem Statement #4 Shelter Experience with Testing A sufficient number of shelters require such TB tests as a condition of em l The same conclusion can be reached with respect to the required testing l 2004 Lenhardt & Colton, LLC 12 March 8, 2004

Problem Statement #5 Immature Administrative Processes l Homeless shelter lack sufficiently mature administrative processes Problem Statement #5 Immature Administrative Processes l Homeless shelter lack sufficiently mature administrative processes to ensure high quality implementation of TB control procedures. (pp 78 -82, 84 -97) 2004 Lenhardt & Colton, LLC 13 March 8, 2004

Problem Statement #5 Essential Administrative Processes l Admitting Residents: The process in operation from Problem Statement #5 Essential Administrative Processes l Admitting Residents: The process in operation from the time a prospective resident enters the shelter to the time the shelter indicates that the prospective resident may stay. l Managing Information: Generating information, and also recording, maintaining and accessing that information when required to make decisions within the shelter. l Screening Residents for TB: l Referring individuals: Determining an health care provider through which Screening for the signs and symptoms of active infectious TB, obtaining TB tests by qualified health care providers, and ensuring those TB tests are read and presented for diagnosis. appropriate medical interventions may be delivered, facilitating the initiation of that relationship, and physically transporting a person with to the facilities of the health care provider. l Training Staff: Teaching staff both what to do and how to do it. Instilling in staff a conviction in the need to engage in the sought-after action. 2004 Lenhardt & Colton, LLC 14 March 8, 2004

Problem Statement #5 Process Maturity Findings l Highest level attained was Level 2: “Repeatable” Problem Statement #5 Process Maturity Findings l Highest level attained was Level 2: “Repeatable” Written documentation has been developed and the practice of the process has become consistent. It is becoming l Level required is Level 3: “Standardized” 2004 Lenhardt & Colton, LLC 15 March 8, 2004

Problem Statement #6 The System-Level Perspective The system that exists to provide TB control Problem Statement #6 The System-Level Perspective The system that exists to provide TB control lacks overall coordination. l A “quarterback” is needed, someone to define the universe of need, to identify the full array of resources to meet that need, to deploy those resources, and to identify and fill the gaps in resource deployment. l (pp 58 -67, 73 -76) 2004 Lenhardt & Colton, LLC 16 March 8, 2004

Problem Statement #6 The System Components l l l Part 1 consists of the Problem Statement #6 The System Components l l l Part 1 consists of the homeless shelters themselves. Part 2 consists of the network of health care providers that provide onsite non-emergency care to homeless shelter residents. Part 3 is comprised of the network of transportation providers that serve the homeless population. Part 4 is the network of health care providers that provide off-site nonemergency are to homeless shelter residents. Part 5 of the system is that component that particularly serves the mentally ill. Part 6 involves that part of the system that provides housing services to homeless shelter residents that have been affirmatively diagnosed with active TB. 2004 Lenhardt & Colton, LLC 17 March 8, 2004

Now What? l Predefine criteria for evaluating potential interventions that address each problem statement. Now What? l Predefine criteria for evaluating potential interventions that address each problem statement. l For each problem statement: – Brainstorm potential interventions – Discuss potential interventions in light of evaluation criteria. – Designate the top four for the strategic plan. 2004 Lenhardt & Colton, LLC 18 March 8, 2004

Evaluating Potential Interventions l Not require additional administrative expenditures of a magnitude that would Evaluating Potential Interventions l Not require additional administrative expenditures of a magnitude that would jeopardize the financial viability of shelters or the current delivery of services. l Not add material administrative workload to shelter staff. A “material” addition involves work that requires the addition of new staff to complete. l Not require expertise that is beyond the scope of a homeless shelter’s mission. Administrative expertise is expected within every organization. l Be equally applicable to all homeless shelters unless explicitly stated otherwise. l Include a complementary package of administrative controls and engineering controls. 2004 Lenhardt & Colton, LLC 19 March 8, 2004

Evaluating Potential Interventions l Promote the development of mature TB control processes. They should Evaluating Potential Interventions l Promote the development of mature TB control processes. They should be documented in writing; independent in their extent, consistency and quality of application from the specific person or persons implementing them; and should not require “heroic” individual effort to implement. l Keep the delivery of medical services within the health care provider community. Homeless shelter staff, for example, do not generally have the training or expertise to deliver TB testing. l Be consistent with the homeless shelter industry’s existing application of the “safe night of shelter” doctrine. l Seek to resolve the incidence of tuberculosis within the homeless shelter community and not merely redistribute it. 2004 Lenhardt & Colton, LLC 20 March 8, 2004

The Continuum of Interventions that Interventions that Enlighten Enable Facilitate Encourage Require Needed actions The Continuum of Interventions that Interventions that Enlighten Enable Facilitate Encourage Require Needed actions progressively more compulsory left l Actions “to the left” are necessary, but may not be s l 2004 Lenhardt & Colton, LLC 21 March 8, 2004

The “How-Why” Analysis: Linking Actions to Outcomes 2004 Lenhardt & Colton, LLC 22 March The “How-Why” Analysis: Linking Actions to Outcomes 2004 Lenhardt & Colton, LLC 22 March 8, 2004

For More Information l Roger Colton Fisher, Sheehan & Colton Boston roger@fsconline. com l For More Information l Roger Colton Fisher, Sheehan & Colton Boston [email protected] com l Steve Colton Lenhardt & Colton, LLC Minneapolis [email protected] com 2004 Lenhardt & Colton, LLC 23 March 8, 2004

Project Objective l Assess operational TB control practices – – – l Client referral Project Objective l Assess operational TB control practices – – – l Client referral & placement procedures Eligibility criteria for shelter admission Intake process for shelter admission Shelter usage vs. capacity Shelter record keeping Policies & procedures for TB control Use interviews, observation, surveys Develop descriptive narrative, not a statistical analysis l Recommend TB control enhancements 2004 Lenhardt & Colton, LLC 24 March 8, 2004

Data Gathering Phase l Shelter Site Visits – Developed broad site visit interview protocol Data Gathering Phase l Shelter Site Visits – Developed broad site visit interview protocol – Conducted six site visits (Aug-Oct) • • • Jefferson Place Atlanta Union Mission Peachtree & Pine Salvation Army Clifton Sanctuary Ministries Boulevard House (Nicholas House, Inc) 2004 Lenhardt & Colton, LLC 25 March 8, 2004

Data Gathering Phase l Written Survey – Focused on five specific issues – 12 Data Gathering Phase l Written Survey – Focused on five specific issues – 12 distributed by mail as pretest • $100 in MARTA tokens offered as incentive • 4 returned – Survey included in October meeting of Metro Atlanta Task Force for the Homeless (Thanks again to Anita Beaty) • $100 in MARTA tokens again offered as incentive • 19 completed 2004 Lenhardt & Colton, LLC 26 March 8, 2004

Data Gathering Phase l Supplemental interviews – Charlotte Marcus (Georgia General Assembly staff) – Data Gathering Phase l Supplemental interviews – Charlotte Marcus (Georgia General Assembly staff) – St. Joseph’s Mercy Care Services • Richard Bernal (Clinic Director) • Xiomara Llaverias (Infectious Disease Coordinator) 2004 Lenhardt & Colton, LLC 27 March 8, 2004