Clinic meets unique outcomes challenge
Measuring outcomes takes more than numbers
We’ve entered the era of accountability, and no one is exempt. The 45th St. Clinic’s Homeless Youth Clinic in Seattle recently received an ultimatum from the United Way of King County, one of the nonprofit clinic’s largest funding sources: Prove your effectiveness or lose your funding.
The Homeless Youth Clinic offers primary care, mental health counseling, HIV testing and counseling, testing and treatment for sexually transmitted diseases, substance abuse counseling, and other services on a no-cost, drop-in basis.
The clinic saw a steep 70% increase in the number of patients it served between 1995 and 1996, and the numbers show no sign of declining. But how do you prove you are improving the health of a population that is indigent, mobile, and extremely distrustful of adults? (For more information about the homeless clinic’s services, see p. 194.)
"We sat down around the table with the United Way representatives and tried to agree upon a logical model of measurable outcomes," says Tom Welsh, MA, development director for the 45th St. Clinic. "They were actually very liberal in allowing us to choose the outcomes we would measure."
Clinic staff identified three outcomes they believe the clinic impacts but which they have never measured formally, says Paul J. Barry, MSW, program coordinator for the Homeless Youth Clinic. Those three outcomes are:
1. increased referrals by providers to HIV prevention counselors;
2. an increased number of immunizations, specifically hepatitis B;
3. a reduction in the number of emergency department visits.
"That’s probably the trickiest one. Unlike other patients who are going to be billed for emergency room care, people who are home- less use the emergency room frequently," Barry says. "We have kids who go to the ER for treatment of head lice."
The first step in the new outcomes project is to gather six months of baseline data starting in January 1998.
"This is all self-reported by our patients. When they come in, we’ll ask them if they’ve been immunized, or been to the emergency room lately," Barry explains. "We actually have very good success in getting our kids to return to the clinic. We build a relationship of trust with them."
The Homeless Youth Clinic works hard to encourage that atmosphere of trust and gain cooperation of a population that’s generally cautious around adults, he notes. "First, we try to reduce the big gulf between their life on the street and the hierarchy of the medical establishment. We try to make them think that the clinic is part of their world."
The clinic uses three formerly homeless youths as outreach workers to talk to young people on the street about the clinic. "They go where the homeless hang out and start conversations about health and the clinic and its services. The homeless young people seem to like the fact that our providers are volunteers," he says.
To break down barriers to treatment, the clinic requires little demographic information from its patients. "We have certain federal requirements such as age and race, but we never ask for social security numbers, and we don’t ask for proof of identification. If they leave half of the form blank, we don’t care. They can still see a provider," Barry says.
In addition, the clinic encourages providers to take their time with patients. "Most of these young people come in with extreme pathology. They may complain about a bump on their leg, but they also have scabies, pneumonia, and maybe chlamydia," he explains. "It takes a while for a provider to get it all out, and adolescents are traditionally poor self-advocates, which makes the process even harder."
Ironically, patients often are more willing to confide in physicians than they are in social workers or counselors, Barry notes. "They like the fact that our physicians are volunteers, and they perceive that medical confidentiality is higher than that of other professionals." In addition, many homeless youths have had prior negative experiences with social workers and counselors.
The clinic is entering this new era of accountability with a degree of apprehension. "We’re all going through quite an in-depth series of outcome evaluation measures," Welsh says. "Once we get our baseline established, we hope that things go smoothly, but it’s not easy to demonstrate outcomes in a transitory population."
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