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Chapter 21 Charlottesville Health Access: A Locality-Based Model of Health Care Navigation for the Homeless Steven E. Bishop James M. Edwards Mohan M. Nadkarni Homelessness in Charlottesville, Virginia, presents a significant public health crisis. This homeless population faces uncommon challenges in both the urban Charlottesville area and the rural surrounding counties. In the city of 41,000, 27.3% of residents live below the poverty line—twice the national average. The population density of Charlottesville proper is 4,048 people per square mile, making it more densely populated than Richmond (3,377 people/sq. mi.), the state’s capital. In comparison , the surrounding counties range from 33 to 131 people per square mile. Thus, urban/suburban Charlottesville differs sharply from its largely rural neighboring counties, with a homeless population that has trouble getting health care. Since 2003, homelessness has been on the rise in the Charlottesville area, with more than 250 adults being reported homeless in 2007. Local school systems indicate that at least 300 children and their families live in shelters or in other substandard conditions. The same report revealed that 44% of those surveyed had medical , dental, or substance abuse problems. Nearly one-half of those surveyed had difficulty obtaining a needed service from the health care system (such as a prescription drug, counseling, or dental care). This indicates a pervasive lack of access to various health care modalities for many of Charlottesville’s homeless citizens. Social inequality has practical consequences for the homeless, including death rates at least four times those of the general U.S. population. Whether one views these facts from a social justice standpoint or from the practicalities of lost economic productivity, they represent a significant public health problem. This problem must be addressed with new models of access. The Charlottesville statistics predate the financial crisis that began in the early fall of 2008 and therefore likely underestimate both the current need for and the difficulty of obtaining health care. Additionally, these statistics do not expound on Stephen E. Bishop, MD, is a resident physician at Virginia Commonwealth University. James M. Edwards, MD, is a resident physician at Duke University. Mohan M. Nadkarni, MD, FACP, is a professor of medicine at the University of Virginia School of Medicine and chief of the Section of General Internal Medicine, University of Virginia Health System. Charlottesville Health Access 223 particular challenges presented by the region’s geography (mainly, that much of greater Charlottesville is rural). Thus, health care for the homeless in this area must be fashioned in order to meet the needs of both the urban homeless within the city and the rural homeless, who live in temporary camps in the surrounding counties. Specifically, transportation and coordination of care must be flexible and affordable enough to account for these different populations. Taken together, the situation demonstrates a pressing need for a new model of health care access for the homeless of Charlottesville. A Solution Charlottesville Health Access (CHA) began in February 2007, when a private, nonprofit community homeless shelter, PACEM (People and Congregations Engaged in Ministry) joined with medical and nursing students and physicians from University of Virginia schools of medicine and nursing (UVA SOM and SON) to organize a health fair for shelter guests. Afterward, medical students began studying existing needs assessment data from the Thomas Jefferson Area Coalition for the Homeless and PACEM regarding the medical needs of the area’s homeless. These discussions led to the formation of a coalition of service providers and recently homeless people that investigated ways of providing a more permanent solution to the health care needs of the homeless in Charlottesville. After the coalition developed a workable plan to enhance access to care for the homeless, CHA was created with the following goals: • Provide a one-stop access point for health care resources for homeless in the Charlottesville region. • Study the care provided, including the number of patients assisted, changes in the number of emergency room visits per homeless patient, and the number of days spent in the hospital per patient, among other variables. • Advocate for easing health care access. • Create opportunities for health profession students: provide a venue to teach about barriers to health care among the homeless, available community resources, and the importance of humanism in medicine. The realization of these goals rests on the shoulders of navigator volunteers, people who have completed a short training course on caring for the homeless, written by Grete vanHorst, RN; Adriana Nicholson of PACEM; Warren Grupe, MD; and...

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