St. Francis House is part of the Social Determinants of Health Consortium
Led by Boston Health Care for the Homeless, a group of seven agencies are working together to help clients, who are experiencing homelessness, improve their healthcare as they establish their own pathways to stability. A Coordinated Care Hub has been developed to provide a centralized system for highly vulnerable homeless individuals with the highest medical needs and costs.
Carli is our representative Social Determinants of Health (SDH) case manager, working with fellow SDH case managers at Boston Health Care for the Homeless, Victory Programs, Boston Public Health Commission Homeless Services, and Casa Esperanza – among other partners.
Carli works specifically with guests who are identified by MassHealth as High Utilizers of Emergency Services.
Working one-on-one with each of the twenty clients on her caseload, Carli helps integrate their care and arrange supportive services to improve their health. These MassHealth members have complex health conditions and face difficulty in managing their physical, mental health, and long-term care needs.
Our collective goal: improving our guests’ health
Carli explains, “Most of my clients have been involved long-term with one or more comprehensive systems, such as the foster care system, legal/penal system, or mental health system, where that system served the role as their parent. As a result, they may not have necessarily fully developed the skills to best take care of themselves and be fully independent. So when they become overwhelmed with this responsibility, they go to the Emergency Room to be taken care of.”
Through effective intervention, Carli guides her clients to utilize other resources that they may not have been aware of, and improve their connections to other healthcare providers and facilities. Her clients are learning how to not resort to the Emergency Room or jail when circumstances do not necessitate it.
For example, one client used to go to the Emergency Room for a warm place to sleep in the middle of the winter, while another client used to intentionally commit petty crimes such as shoplifting in order to go to jail when their chronic illness became too difficult to manage on the street. Others have used jail as a way to access detox or long-term substance use treatment.
Determination, patience, and grit
Recently, a client fell ill and had to be admitted to the hospital. When Carli visited, the hospital staff were so amazed how the client’s demeanor immediately changed. In her presence, he was calm, contrite, and willing to listen. It takes a lot of empathy, patience, and trust-building for Carli to successfully connect with each of her clients. However, it is through this connection that they are able to learn new habits and discover their individual pathways to stability.
In the long run, Carli is helping her clients streamline their access to care, enhance the quality of services they receive, and learn how to proactively communicate their physical and mental health needs, thus decreasing the use of unnecessary emergency services.