Follow-up review. Healthcare for the Homeless Program, Department of Community Health

FOLLOW-UP REVIEW

Healthcare for the Homeless Program Department of Community Health March 2002

Performance Audit Operations Division Russell W. Hinton, State Auditor Department of Audits and Accounts

254 Washington St. S.W. Atlanta, GA 30334

This is a Follow-up Review of the Performance Audit of the Homeless Services Program conducted by the Performance Audit Operations Division in December 1999. In September 1999, an Executive Order was signed transferring the Program from the Department of Human Resources to the Department of Community Health. The order was retroactive to July 1999. In January 2000, the Program was placed within the Office of Rural Health Services (ORHS) and renamed the Healthcare for the Homeless Program.

The purpose of the Program is to provide primary and preventative healthcare to homeless [persons] in Savannah and the metro Atlanta area to improve the health care outcomes for this population. The Program seeks to accomplish this by contracting with St. Joseph's Mercy Care Services (SJMCS) in Atlanta and with the Chatham County Board of Health in Savannah, which, in turn, contracts with Union Mission, Inc.
Both SJMCS and Union Mission provide an array of services to the homeless population including medical, dental, and substance abuse services. In fiscal year 2002, the state provided $167,695 to SJMCS; this represents an increase of $100,000 since the 1999 audit. SJMCS has an annual budget of approximately $8 million. The state and SJMCS have identified state funding as supporting the clinic in the basement of St. Luke's Episcopal Church and the Resource Opportunity Center (ROCK). At these two facilities, a nurse practitioner and a medical assistant provide treatment for chronic diseases and episodic health problems. In fiscal year 2002, the state provided $223,602 to the Chatham County Board of Health for healthcare services for Savannah's homeless population; this amount has not changed since the 1999 audit. The state's funding represented 5.5% of Union Mission's $4.09 million budget. DCH and Union Mission have determined that funds will be allocated across all of Union Mission's operations. Union Mission operates health clinics at three sites. Union Mission also works with the Phoenix Project, which provides primary medical care for persons living with HIV/ AIDS.

The audit found that the Program was fulfilling its purpose of providing healthcare services to the homeless populations in Atlanta and Savannah. However, we also determined that the Program needed to develop appropriate objectives that would reflect its effectiveness in improving the health outcomes of the homeless population; explore other options in service delivery methods; and better monitor the contractors' performance.

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Recommendation as reported in 1999: Action should be taken to discontinue having the Homeless Services Program operate as a separate program (or initiative). By including Homeless Services funds in the counties' grant-in-aid contracts, the Department could reduce the paperwork and reporting requirements associated with having a separate program. If the Program is continued as a separate program, however, action should be taken to develop goals and objectives, establish monitoring procedures, and identify effective service delivery methods. Current Status: With the move to DCH, the structure of operating as a separate program with one contract administered through grant-in-aid and one administered directly has remained the same. As noted in the original report, it was determined that the contract with SJMCS could not be included in the grant-in-aid funds provided to the Fulton County Board of Health due to the structure of the Board. While the Program's structure remains the same, DCH noted that the program is a major initiative and action has been taken to develop a comprehensive approach to meeting the needs of the homeless. In addition, while St. Luke's Clinic was the only facility being funded with state monies at the time of the original audit, state funds now also support activities at The ROCK of Atlanta. Given the recent changes to the program, consideration should be given to developing goals and objectives which address the services provided by SJMCS and Union Mission as a whole, in addition to the benefit the state receives by providing this funding, instead of focusing on activity at the individual clinics which are funded with state monies. As described in the following findings, action is being taken to develop goals and objectives, monitor the activities of the contractors and evaluate service delivery methods.
Recommendation as reported in 1999: The Homeless Services Program is fulfilling its overall purpose of providing healthcare services to the homeless in Atlanta and Savannah. Clinic staff report the capacity to treat the majority of patients they see and the ability to make referrals as necessary. However, action should be taken to improve the management of the contracts. Current Status: Based on our review of programmatic and statistical reports submitted to ORHS by the contractors, it appears that the Program is continuing to provide basic healthcare services in Atlanta and Savannah. During calendar year 2000, SJMCS reported a total of 24,722 encounters. During fiscal year 2001, Union Mission reported 8,741 encounters (calendar year data was not available). It should be noted that an encounter is defined as a visit by an individual patient; however the same patient may make multiple visits and therefore be counted as multiple encounters. Both Union Mission and SJMCS also have access to an array of other services to which homeless patients can be referred if necessary.
Recommendation as reported in 1999: The Program should establish appropriate and achievable objectives to measure its overall effectiveness in improving the health outcomes for homeless persons in Atlanta and Savannah. While its stated goal is to improve health outcomes for the homeless populations in Atlanta and Savannah, the Program has not established any means for determining if it is achieving its goal or for measuring its impact. Current Status: Both contractors have taken steps to develop their own goals and objectives. Goals for SJMCS include expanding availability of dental services, improving the health status of homeless

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women and children by increasing accessibility and availability of health services, and increasing access to mental health and substance abuse services. Union Mission's objectives include directing homeless people away from hospitals; through coordination with other providers, including a substance abuse program as part of the shelter based continuum of care; and continuing to grow dental services.
Recommendation as reported in 1999: The Program should establish a systematic method for monitoring the contractors' performance. Currently, the contractors are not required to provide specific information regarding their performance. In addition, the Program has not enforced the requirement that contractors submit quarterly reports, nor has it been in regular contact with contractors to ensure that services are being provided as required. Current Status: The contractors are required to submit monthly, quarterly, and biannual reports to the ORHS. According to Program staff, these reports determine the overall effectiveness of the Program, and they help to identify health care trends that need to be addressed by additional initiatives. These reports provide detailed information about the number of patients, the demographics of the patients, and the Program's expenditures. In addition to requiring the contractors to submit written reports, representatives from the ORHS have made three site visits to the clinics to evaluate the contractors' performance.
Recommendation as reported in 1999: The Program should determine what type of service delivery method best meets its overall goal of increasing the homeless population's access to primary health care services. By their own choice, both contractors currently use fixed clinic sites; however, this method of service delivery has not been independently evaluated by the Department. Current Status: The Program is currently in the process of determining which service delivery method best meets the needs of the homeless population. The fiscal year 2002 contract requires both contractors to submit a biannual needs assessment and a final program report. According to Program staff, these reports will be used to evaluate the effectiveness of the delivery services. The Program plans to conduct ongoing evaluations of the Program's objectives and performance results to determine if changes in the current delivery plans or other initiatives are warranted.

For additional information or to request a copy of the original report, please contact Paul E. Bernard, at 404.657.5220 Or see our website: www2.state.ga.us/Departments/AUDIT/pao/followup.htm

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