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photo of Alicia Hauff

A single assignment

Nursing graduate leads effort to provide care to the homeless

Alicia Hauff is determined, focused, organized and systematic, and matter-of-fact. If something needs to be said, she’ll say it. If something needs doing, she’ll take it head on. She had been a cardiac intensive care nurse for a few years, and had begun working on a doctor of nursing practice degree at North Dakota State University when one of her early projects would show her something that needed doing.

For the project, she needed to do an assessment of a population with unmet health-care needs, and Hauff thought the homeless population seemed like an obvious choice. She began by talking with eight community members, who all told her a medical respite care program was one of the greatest needs in homeless health care.

“They all said, heck yes, we need this,” she said. “Especially the social workers, because they’re the ones who are constantly trying to find places for these people to be safe after a hospitalization.”

Hauff had never heard of homeless respite care before that first set of interviews. She understood respite care, of course, but had never considered it in the context of homelessness.

On the other hand, people who work with homeless had known about the need for many years, but making it a reality seemed nearly impossible. Funding, facilities, nurses, staff, training, regulations, cooperation among multiple health organizations and providers — it all needed to be sifted through and coordinated. Someone needed to do the legwork.

Homeless medical respite care provides a stopgap between hospitalization and the time when people are once again able to care for themselves. It’s a place for homeless people who are well enough to be out of the hospital but too sick to be on the streets to rest and recuperate from illness, injury or surgery. They get medical care, but also support services that help with things like setting up follow-up visits and, ideally, finding permanent housing.

As she looked into homeless care for that first assessment, Hauff learned that respite care often is not an option for people who don’t have roofs over their heads, let alone insurance to cover the costs. No program or facility exists. The only alternative is shelters that aren’t equipped to provide the level of medical care many homeless patients need. Many of the patients also struggle with issues related to mental health, substance abuse and lack of transportation that complicate matters even further.

When it was time for the final project in her program, Hauff started a more comprehensive homeless health needs assessment in Fargo-Moorhead, this time with a focus on formally evaluating the need for homeless respite care. And she dug deeper, reviewing existing research and studying homeless respite care programs in other communities.

“I was learning about complex issues that limit access to care and systemic societal problems that drive these issues for homeless people,” she said. “I realized the ways we’re doing things now are ineffective. We need to make investments into programs that not only help people, but save society a lot of money.”

Homeless people tend to use emergency departments more often than the general population because they don’t have insurance or primary physicians, and stay in hospitals longer because discharge teams can’t find places for them to go. Then the lack of respite care after discharge often leads to re-hospitalization.

Programs in cities like Washington, D.C., and Boston have proven their value year after year, helping save hundreds of thousands, and in some cases millions of dollars. Most mid-sized communities like Fargo-Moorhead don’t have programs, for any number of reasons.

“When you’ve seen one medical respite program you’ve seen one medical respite program,” Hauff said. In other words, each program has to be tailored to the specific community with its unique needs, requirements and funding mechanisms.

The second assessment included interviews with physicians, nurses, paramedics, city planners, social workers and the people with the most at stake, Fargo-Moorhead’s homeless. Hauff collected data related to homeless health needs, factors that affect them and resources in the community. She finished her report and recommendations in 2013, and immediately began assembling a taskforce to address the problem head on.

After finishing her doctorate, Hauff quickly put together a working group of professionals in homeless health to begin addressing the need for respite care. Then she went to Kim Seeb, director of Homeless Health Services, to ask for a job. She’s now a family nurse practitioner who sees homeless patients each weekday morning. Twice a week she also provides outreach care at the Cass County Jail in Fargo.

“Alicia is very compassionate and creative in how she addresses things, like developing a treatment plan for someone with multiple factors contributing to their health issues,” said Seeb, who is a member of the working group. “We’re lucky to have her.”

Hauff also got more deeply involved with the homeless coalition, where she continues to be the driving force for developing a homeless medical respite care program. The coalition now has funding, has been looking at potential sites and hopes to launch a limited pilot this year with basic care and beds for a handful of men at a time.

Another member of Hauff’s working group is Gina Nolte, director of health promotion at Clay County (Minnesota) Public Health. She said the working group wouldn’t have made anywhere near the progress it has without Hauff driving the process.

“This all came about because of Alicia’s research study,” Nolte said. “Without all her focus on that work and engaging and involving all kinds of stakeholders, and how she’s kept it moving even after finishing school, this wouldn’t be happening.”

Hauff is already talking about her hopes to expand the respite care program to take on more complex cases and include beds for women. She also would like to see other North Dakota communities using Fargo-Moorhead as a guide in creating their own programs. After that, there are dozens of other homeless health service needs to address. “It’s complicated,” she said, “but we have to start somewhere.”

— martin fredricks

Student Focused. Land Grant. Research University.