This article is part of State of Health, a series examining health disparities, how they affect Michigan's children and seniors, and the innovative solutions being developed to address them. It is made possible with funding from the Michigan Health Endowment Fund.

Imagine being a gay or lesbian teenager thrown out of your home, living on the streets, finding out you're HIV positive, and trying to navigate the healthcare system your own. Or imagine being a homeless transgender teen getting jeered at by other patients in the waiting room of a community health clinic.

That was the reality for many of the clients served by the Ruth Ellis Center (REC) in Highland Park, says Mark Erwin-McCormick, director of development and advancement for the center.

The organization's drop-in center was already offering "low-barrier" access to food, showers, laundry facilities, recreation, and peer support. But when staff asked how they could better serve their clients, they found that the homeless LGBTQ youth they served were still facing significant barriers in accessing primary care services.

Youth at the Ruth Ellis Center wrote these descriptions of what the center means to them.

"We found out that not only were more than 90 percent not connected to primary care, about 40 percent were already living with HIV," Erwin-McCormick says. "When you don't have family support and you're experiencing identity-based rejection, it's really hard for a young person to navigate the healthcare system or enroll in Medicaid when you're 16 or 17."

REC staff responded by using private funding to add a health and wellness clinic to the ground floor of a building they were already using as a drop-in center. They also chose not to accept any federal funding, which would have required them to open the clinic to the broader community.

Mark Erwin-McCormick.

"The idea behind it was that we need this to be a safe space for LGBTQ young people," Erwin-McCormick says.

Dr. Maureen Connolly, the practitioner who works with homeless LGBTQ youth at REC, says she and other REC staff weren't sure how popular the health and wellness clinic would be, but the number of repeat visits by the same patients indicates it was sorely needed.

"I had a sense when we first started that these teens had so much going on in their life. Would they even have healthcare on their list of priorities? Was it something they want to make time for?" she says. "What we found was that if we make it accessible, yes, absolutely. They're concerned about their health and they follow up really well."

REC is just one of many healthcare clinics around Michigan that are finding creative ways to address the social determinants of health and provide healthcare to Michigan's most vulnerable residents, the homeless.

Special health challenges for the homeless

Eric Hufnagel, executive director of the Michigan Coalition Against Homelessness, says the organization's data from 2016 shows about 10 percent of homeless children and about 20 percent of homeless adults are dealing with some kind of long-term disability or chronic health issue, including physical illness, mental health issues, and substance use disorders.
Lacking insurance is a huge risk factor for falling into homelessness in the first place, and people who are homeless and uninsured experience higher mortality rates.

Luckily, policy changes in recent years mean that most homeless adults and virtually all homeless children are covered by some type of insurance, usually Medicaid for minors. But insurance coverage alone doesn't solve the healthcare access issue.

Dr. Wendy Ringo, executive director of the Genesee Community Health Center (GCHC), says housing insecurity is at the root of many of the social determinants of health.

"If you're living on the streets or in shelters or you're couchsurfing, it's difficult to adhere to a blood pressure regime or have a refrigerator where you can make sure your insulin is cooled at a proper temperature," Ringo says.
 

Wendy Ringo

Having a housing safety net is very important, Ringo says. If someone is putting all their energy into finding a stable home, health concerns will be put on the back burner. Once someone has housing, they'll have time and energy to schedule a checkup or have a troublesome tooth examined.

As a woman experiencing homelessness in the Grand Rapids area, Maiya Copeland knows these challenges all too well. Copeland's 6-year-old daughter receives care at federally-qualified health center Cherry Health for allergies, breathing issues, and eczema. Copeland's daughter has a semi-permanent place to stay with friends, but Copeland copes with her lack of housing by staying with friends a few days a week and sleeping in her car the rest of the time.

When she was abruptly asked to leave her previous apartment, she had to hastily throw all her and her daughter's belongings into her car. It took Copeland some digging around to find her child's inhaler and eczema ointment. If her daughter's breathing issues worsen, the situation gets even more precarious.

"She has allergies, and they have her on a (nebulizer), and it's hard trying to keep that in a safe, cool area," Copeland says. "If she needs her breathing treatments, and she's living at somebody else's house, I have to hurry up and drive over there to help with that."

Copeland recently received a voucher for housing but was told there won't be an opening until November.

"My daughter's problems are worse in the wintertime," Copeland says. "Hopefully, this (housing opportunity) comes through, because I do not want to go through this in the wintertime."

Searching for successful strategies

Healthcare organizations across Michigan are implementing a variety of innovative strategies to make healthcare more accessible to Michigan's homeless. Most recently, GCHC bought a 16-passenger van and a smaller minivan to address transportation-related barriers to care. Transportation arrangements are integrated into the appointment-scheduling process, so a front desk staffer can set the appointment and arrange for transportation all at the same time.

Other GCHC strategies include offering ready-to-eat foods through a food pantry at every health clinic site, using social workers to assess clients' needs and connect them to other community resources, offering medicines to assist clients who want to stop drinking alcohol or using drugs, and using "geo-fencing" to send out smartphone alerts to people in a certain geographic area.

"We can send out specific messages to, say, around the bus depot, where we know a lot of homeless individuals are congregating," Ringo says. These alerts allow health center staff to send out the message that there's a free clothing giveaway or that the clinic is offering free flu shots.

Cherry Health CEO Tasha Blackmon says about 10,000 of the 80,000 clients Cherry Health served in 2017 were homeless. Of those 10,000, about 26 percent are under age 18, and 48 percent are people of color.
 

Cherry Health CEO Tasha Blackmon

Cherry Health makes it a priority to establish clinics within walking distance of areas where potential clients congregate. They also co-locate many services, such as vision and dental exams, on one site so that clients don't have to drive to multiple locations for specialty care. Additionally, clients can pick up their medications in the same building where they were seen by the healthcare team.

To get to the root of homelessness, in 2015 the Ruth-Ellis Center started a Family Preservation pilot program designed to help LGBTQ children and youth stay connected to their families so that they might not have to experience homelessness in the first place. The program trains Child Protective Services case managers to provide home-based family support services and identify abusive behaviors related to the child's identity and gender expression.

But for those who do experience homelessness and need help, there's an emphasis on co-location of services.

"We believe in bringing healthcare to these vulnerable people in a way that has not been done before, co-located with the drop-in center," Erwin-McCormick says. "The center has been there almost 20 years, and we've established a level of trust like nobody else."

The health and wellness center at REC doesn't just provide acute care and care for chronic illness, but also "affirming care" for transgender youth, whether that's access to hormones or referrals for gender-affirming surgeries, a type of speciality care that isn't often included in a primary care health clinic setting.

Not just tolerated, but welcome

Beyond specific strategies and programs, many providers emphasize that homeless patients are sensitive to the attitudes of healthcare providers and community members.

At Cherry Health's Heart of the City center in downtown Grand Rapids, homeless folks are always sitting on benches around the health center and frequently come in to charge a cell phone or use the bathroom. They aren't just tolerated, but welcome, Blackmon says.

"It's important for us to treat people with dignity and respect, even if they're getting onto the elevator with you and talking to themselves," Blackmon says. "We don't want to be an organization that says you have to look or smell a certain way to be able to have access to quality, affordable healthcare. We want to meet you exactly where you are and provide interventions, if you want them, around food, housing, and healthcare. We're welcoming to all. We want to be a beacon."

Connolly says that although she witnesses hard things in her work, she wants people to know it's not all gloom and doom. She says she's impressed by the resiliency and creativity that her patients show in surviving and getting what they need.

"It can be sad and frustrating, because there's a lot that they're facing," Connolly says. "But what I see all day is people who understood who they are and are living their truth, their authentic lives, and that's more than you can say about a lot of people. There's a lot of positivity and community-building, and that's inspiring."

Wendy Ringo photo by Mike Naddeo. Mark Erwin-McCormick photo courtesy of Mark Erwin-McCormick. Tasha Blackmon photo by Adam Bird. All other photos by Nick Hagen.