2004 lenhardt & colton, llc needs assessment of fulton county homeless shelters march 8, 2004

2004 Lenhardt & Colton, LLC

Needs Assessment of Fulton County Needs Assessment of Fulton County Homeless SheltersHomeless Shelters

March 8, 2004March 8, 2004

2004 Lenhardt & Colton, LLC Slide 2 March 8, 2004

Infrastructure Issue-Infrastructure Issue-WHAT is a Homeless Shelter?WHAT is a Homeless Shelter?

The state must be able to define the institutional target of TB control efforts.

The definition must be based on objective criteria rather than on shelter services or on shelter funding sources.– An issue with multi-program facilities.

There is an clear distinction between “overnight” and “extended stay” shelters.

(pp 19-26)


Infrastructure Issues-Infrastructure Issues-Inventory of Homeless SheltersInventory of Homeless Shelters

The state must be able to identify (I.e., list) the institutional targets of TB control efforts.

Today, there are many different “lists”.– 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.


Problem Statement #1Problem Statement #1Risks of TB Not AcknowledgedRisks of TB Not Acknowledged

Shelters believe that the risks presented by TB are not as great as other risks facing the homeless.

Not that the control of TB is unimportant- just not as important as other shelter issues.

(pp 67-70)


Problem Statement #1Problem Statement #1Risks vs. Shelter ResourcesRisks vs. Shelter Resources

“The lack of immediacy appears to be a greater barrier to undertaking TB control processes than the lack of shelter resources.”

Implementation of TB Control Procedures and Perception of TB Riskwithin Fulton County (GA) Homeless Shelters

Immediate Risk Insubstantial Risk No Indication of Risk

Implementing 2 0 2

Assigned staff 0 0 1

No staff assignment 0 0 3

No time/resources 2 2 1

Low priority 0 0 2


Problem Statement #2Problem Statement #2Non-Custodial InstitutionsNon-Custodial Institutions

Homeless shelters are non-custodial institutions. 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 – Return to have the test “read” – Obtain and/or complete treatment if active TB diagnosed.

(pp 45-51, 52-53, 60-61)


Problem Statement #2Problem Statement #2Insights from Mercy Care ServicesInsights from Mercy Care Services

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%.

“The consensus was that the majority of individuals not returning to have their PPD skin test read were sheltered at overnight emergency shelters.”

“Conversely, individuals sheltered in transitional or other extended-stay shelters were more likely to have their PPD skin tests read.”


Problem Statement #3Problem Statement #3 Absence of Engineering Controls Absence of Engineering Controls Engineering TB controls such as ventilation systems and/or HEPA

filters are effective at reducing the incidence of TB. Homeless shelters do not have the capability to install engineering

controls.– 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.

Shelters have no incentive to procure or develop staff, expertise, and resources.

(pp 38-44)


Problem Statement #3Problem Statement #3Engineering Controls @Site VisitsEngineering Controls @Site Visits 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.


Problem statement #4Problem statement #4Lack of TB ExperienceLack of TB Experience

Homeless shelters lack the experience with TB upon which to base the development of effective TB control protocols.

Shelters lack the ability to self-define what would constitute an effective comprehensive TB control program.

(pp 51-54, 54-58)


Problem Statement #4Problem Statement #4Lack of TB Control ProtocolsLack of TB Control Protocols 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.

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.


Problem Statement #4Problem Statement #4Shelter Experience with TestingShelter Experience with Testing

A sufficient number of shelters require such TB tests as a condition of employment to demonstrate that these requirements are neither onerous nor unworkable.

The same conclusion can be reached with respect to the required testing of homeless shelter residents at extended stay shelters.

Number of Written Survey Respondents EngagingIn Specified Worker and/or Resident TB Testing

Fulton County (GA)

Worker Testing Resident Testing

At Time ofHiring

OngoingAt Time ofFirst Stay

Ongoing

Require TB test(s) 7 7 11 8

Encourage TB test(s) 8 9 4 4

Neither encourage nor discourage TB test(s) 5 6 8 8

NOTE: Difference in totals indicates that not all shelters responded to all questions.


Problem Statement #5Problem Statement #5Immature Administrative ProcessesImmature Administrative Processes Homeless shelter lack sufficiently mature

administrative processes to ensure high quality implementation of TB control procedures.

(pp 78-82, 84-97)


Problem Statement #5Problem Statement #5Essential Administrative ProcessesEssential Administrative Processes 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.

Managing Information: Generating information, and also recording, maintaining and accessing that information when required to make decisions within the shelter.

Screening Residents for TB: 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.

Referring individuals: Determining an health care provider through which 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.

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.


Problem Statement #5Problem Statement #5Process Maturity FindingsProcess Maturity Findings

Highest level attained was Level 2: “Repeatable”Written documentation has been developed and the practice of the process has become consistent. It is becoming more common for tasks to be done the same way every time and the process knowledge has become somewhat disseminated within the work group. Process indicators are defined, monitored and

used to maintain control of the process. Level required is Level 3: “Standardized”

Maturity of Target Processes within Shelters Visited

TargetedProcess

JeffersonPlace

AtlantaUnion

MissionBoulevard House

SalvationArmy

CliftonSanctuar

y

Peachtree& Pine

Admittingresidents

Ad-Hoc Ad-HocRepeata

bleRepeata

bleAd-Hoc Ad-Hoc

Managinginformation

Repeatable

Ad-HocRepeata

bleRepeata

bleAd-Hoc Repeatable

Screeningresidents for

TB /a/Ad Hoc Ad Hoc Ad Hoc Ad Hoc Ad Hoc Ad Hoc

Referringsuspected

TB cases /a/Ad Hoc Ad Hoc Ad Hoc

Repeatable

Ad Hoc Ad Hoc

Trainingstaff on TB-related issues

Ad Hoc Ad Hoc Ad Hoc Ad Hoc Ad Hoc Ad Hoc


Problem Statement #6Problem Statement #6The System-Level PerspectiveThe System-Level Perspective

The system that exists to provide TB control lacks overall coordination.

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.

(pp 58-67, 73-76)


Problem Statement #6Problem Statement #6The System ComponentsThe System Components Part 1 consists of the homeless shelters themselves. Part 2 consists of the network of health care providers that provide on-

site 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 non-

emergency 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.


Now What?Now What?

Predefine criteria for evaluating potential interventions that address each problem statement.

For each problem statement:– Brainstorm potential interventions– Discuss potential interventions in light of

evaluation criteria.– Designate the top four for the strategic plan.


Evaluating Potential InterventionsEvaluating Potential Interventions

Not require additional administrative expenditures of a magnitude that would jeopardize the financial viability of shelters or the current delivery of services.

Not add material administrative workload to shelter staff. A “material” addition involves work that requires the addition of new staff to complete.

Not require expertise that is beyond the scope of a homeless shelter’s mission. Administrative expertise is expected within every organization.

Be equally applicable to all homeless shelters unless explicitly stated otherwise.

Include a complementary package of administrative controls and engineering controls.


Evaluating Potential InterventionsEvaluating Potential Interventions

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.

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.

Be consistent with the homeless shelter industry’s existing application of the “safe night of shelter” doctrine.

Seek to resolve the incidence of tuberculosis within the homeless shelter community and not merely redistribute it.


The Continuum of InterventionsThe Continuum of Interventions

Needed actions progressively more compulsory left-to-right

Actions “to the left” are necessary, but may not be sufficient.

Interventions that

EnlightenInterventions that

EnableInterventions that

EncourageInterventions that

RequireInterventions that

Facilitate


The “How-Why” Analysis:The “How-Why” Analysis:Linking Actions to OutcomesLinking Actions to Outcomes

fl HowPrepare modelbest practice TBcontrol protocols

Why ‡ fl HowIncrease shelteruse of bestpractice TB

control protocols.

Why ‡ fl HowMaximize shelterability to identifyTB within shelter.

Why ‡ fl HowMinimizeincidence of

active TB withinshelter.

Why ‡ fl HowMinimizetransmission of

TB within shelter.

Why ‡ Reduce incidenceof TB in

homeless shelterresidents


For More InformationFor More Information

Roger ColtonFisher, Sheehan & [email protected]

Steve ColtonLenhardt & Colton, [email protected]


Project ObjectiveProject Objective

Assess operational TB control practices– 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, surveysDevelop descriptive narrative, not a statistical analysis

Recommend TB control enhancements


Data Gathering PhaseData Gathering Phase

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)



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



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 needs assessment of fulton county homeless shelters march 8, 2004

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