Homelessness & Public Health: How Can We Close the Gap?

Challenges in areas ranging from education to the environment, gender to governance, health to housing don’t exist in a vacuum. Each month, Abt experts from two disciplines explore ideas for tackling these challenges in our monthly podcast, The Intersect. Sign up for monthly e-mail notifications here. Catch up with previous episodes here.

Homelessness. COVID-19. Each is a crisis in its own right, but Abt’s recent work with HUD and CDC highlights the benefits of addressing homelessness and public health as related challenges. Natalie Matthews and Terri Mota connect the dots and discuss how we can do more moving forward.

For more on this topic, listen to Episode 17: Turning the Tide—Systemic Racial Inequities and the Social Determinants of Health.

Read the Transcript

Eric Tischler: Hi, and welcome to The Intersect. I'm Eric Tischler. Abt Global tackles complex challenges around the world, ranging from improving health and education to assessing the impact of environmental changes. For any given problem, we bring multiple perspectives to the table. We thought it would be enlightening and maybe even fun to pair up colleagues from different disciplines so they can share their ideas and perhaps spark new thinking about how we solve these challenges.

Today, I'm joined by two of those colleagues, Natalie Matthews and Terri Mota. Natalie leads Abt's HUD technical assistance team. Her expertise is in the areas of homelessness, coordinated entry, system modeling, capacity building, data analysis, policy development, and homeless management information systems. Terri has almost 30 years of experience as a registered nurse. Her expertise is in geriatric nursing and she serves as an associate scientist and nurse researcher on several Abt long-term care federal and state contracts. Welcome.

Terri Mota: Hi, Eric. Hi, Natalie.

Natalie Matthews: Hey, Terri. Great to talk to you both.

Eric: At Abt, we work on all of the social determinants of health, helping our clients tackle the specific challenges they've been organized to address. However, on Abt's side of the fence, we keep talking about how those determinants--such as housing, education, workforce, health--are connected, but often the work on those issues isn't. However, Natalie and Terri have teamed up to address COVID among people experiencing homelessness, and we thought it'd be great to talk about lessons learned and how we can leverage those lessons moving forward.

So to start, Natalie, can you tell us what the HUD TA team typically does, and how you segued into COVID work?

Natalie: Absolutely, I'd be happy to. So Abt's homelessness technical assistance team is composed of about 20 of us, and we primarily all come from backgrounds of working directly in communities. So many of us, day in and day out, work really closely with communities to help them strengthen their planning efforts, to help strengthen their data collection and analysis efforts, make improvements to programs, just really help them as they work towards ending homelessness. Ensure that they're doing sort of the best, most strategic work possible that really centers, ideally, people experiencing homelessness in that work. We've been doing that work as a team for well over 10 years now at Abt, working primarily for HUD, but also with contracts through the VA, and other federal partners and local entities.

And really, our work related to COVID started very soon after COVID started itself. So in late March, we were tasked by HUD to join a newly formed disaster and public health response team, that was this partnership between HUD, the Centers for Disease Control [and Prevention], and organizations like National Healthcare for the Homeless. And it was a very quick pivot. Everything really switched in that moment to needing to ensure that our technical assistance to communities was inclusive of, again, public health guidance, disaster response, and really ensuring that communities had the information that they needed to respond as quickly and effectively as possible to this pandemic that we were all going through.

Eric: Great. So Terri, how did you get involved and what did you bring to the process?

Terri: I'll start off with our division. So in the Division of Health an Environment, or DHE, we provide-

Eric: That's Abt slang by the way, for our listeners.

Terri: We provide innovative evidence-driven advisory assistance to the clients that we serve, and that contributes to the bettering of health and safety of individuals and families and communities. So, like Natalie was saying, we have a background of working in communities. The work that we do contributes to Abt's overall mission to improve the quality of life and wellbeing of people worldwide. So in the work that we do in DHE, it requires that we have those appropriate skillsets, right? That includes an understanding of cultural competency and equity, as well as the ability to provide technical assistance that's accessible and tailored for the diverse audiences that we see across the healthcare spectrum to be able to address different people's needs.

And with my 27 years of experience as a nurse, and quality improvement professional, and the colleague who worked with me, who's not on the podcast today, Steven Hines in DHE, he has extensive experience in communications. So we brought these skill sets and our work experiences in both federal and state sectors in DHE to this project. And we were introduced to this project actually through Chris Spera, who was connected by somebody in SEP [Social and Economic Policy], to say that it would be good to have this collaboration between these two divisions within Abt.

Eric: SEP being the division that Natalie's in.

Terri: Yeah, and so in the contracts that I specifically am involved with, I provide direct education and technical assistance to providers, patients, and caregivers in all different settings of care. And in collaboration with our colleagues as part of the HUD technical assistance communication team, what we do in DHE really fits into what we were tasked to do there, which was to provide those technical assistance supports via communication to the communities and stakeholders in the continuum of care leadership and frontline workers that specifically helped them plan and prepare for, and respond to the issues related to COVID-19, especially related to the equitable vaccine distribution to people experiencing homelessness.

Eric: You want to talk a little bit more about that? The equitable distribution?

Natalie: Yeah, Terri, do you want me to jump in or did you want to start?

Terri: Sure.

Natalie: Okay. So it's a great question and was really a central part of the work that we were embarking on. So, at the time of really starting to think about vaccine distribution, it was really important for, from HUD's perspective, to ensure that we were able, as TA providers, to help communities with prioritization planning at the local level. So there was some guidance, of course, given by the CDC that was very strongly encouraging that vulnerable populations, including people experiencing homelessness and folks that work with people experiencing homelessness, are prioritized for the vaccine. However, it was all decentralized at the state and the local level in terms of what the priorities actually were, who was actually prioritized for that vaccine. So, we know that homelessness is something that was a crisis well before the pandemic, but it was something that the pandemic really shined a light on in terms of the vulnerabilities that people experiencing homelessness always faced, and how those intersect with public health situations, including a pandemic like COVID-19.

So, we know the homeless population in general is aging quite significantly. It tends to be comprised of a significant percentage of older adults. We also know that homelessness very disproportionately impacts black, indigenous, people of color, and that likewise COVID-19 has put communities of color at increased risk as well. And so it's been very important in vaccine planning to ensure that we're providing guidance and support to communities, to help them really advocate, to ensure that people experiencing homelessness are really central in the thinking of public health officials when they're coming up with those vaccine plans. And I believe, Terri, that you and several of your colleagues worked on products, right, that really helped identify some strategies for communities to put in place to really think through those prioritization efforts for vaccines.

Terri: You know, the interesting thing too, is that we were asked to provide it in different formats. So some of it was basically just infographics. So, for people who may have some low literacy skills, it was pictures. For some folks, it was talking points, not necessarily a specific product, but it was specific talking points that were directed towards specific groups of people. So they really, I think in this whole endeavor really tried to expand the ways to communicate to the people that they needed to communicate to, those vulnerable folks. I mean, you think of people that are sheltered homeless, they have a little bit more access to things. They might have access to a computer or a telephone and things like that, but then you've got folks that may be unsheltered and how do you get this information to them? And so I think that a lot of that came out in looking at and considering ways to communicate to people. It's not really something that you think of on a daily basis, because we're so exposed to this technology all the time. And when you have to start thinking about people who need to get information, especially vital healthcare information, and they don't have access, how do you reach them? It's really a question that I did not consider much until I came on this project.

Natalie: I'm really glad you mentioned that, Terri, because I think one of the other things that I really didn't necessarily think of before this work is that, a lot of the general public health guidance related to COVID, were things like stay at home, social distance. Things that if you're experiencing homelessness, you can't do. So, this work on vaccine planning and distribution was really another example that highlighted the need for really having responsive resources and resources that could meet people where they were and really help people regardless of their living situation with staying safe and staying well during a pandemic.

Eric: So that, I think, segues to what I was going to ask, which is, having teamed up, how do you feel that collaboration has helped each of you expand your work, and where might there be opportunities to do this in the future?

Terri: Do you mind if I go first, Natalie?

Natalie: Oh, please. Go for it.

Terri: Okay. I think that part of it is that it challenges some of those standard assumptions we have about, as I was saying, about healthcare and access to it. So, for example, there are times in our technical assistance provision that we might tell patients that they need to consult their primary care physician related to a particular condition, but having been involved in a project where the population of focus is on those experiencing homelessness, you start to think about how you approach this issue of primary care, as many who are experiencing homelessness don't have a primary care physician to consult with. So the access is very different. Another benefit of this collaboration was really in the recognition that there are a lot more types of people who are experiencing homelessness than we would really expect and which we kind of touched on a couple of minutes ago. As they say, some people may only be a paycheck away from losing their home.

There's something that really hit me working with this team, because we're not dealing with the typical stereotype that we hear about all the time and about those who are experiencing homelessness, that they have substance use disorder or they must have mental health issues. It's really applicable to just about anyone. People who have children, people who have college degrees, maybe teenagers who've left their home for whatever reason. But what this means in our work is that we really have to pay close attention to this issue of homelessness, because people in this situation will all have different needs depending on their particular circumstance, and there's really no one size fits all approach.

And to give a concrete example in some of the work that I do, in one of our projects, we're providing education and technical assistance to nursing homes related to the continuation of medication assisted treatment for opioid use disorder. So these are folks who've been through detox, they're in the acute care setting, and they now need to receive skilled services from a nursing home. But prior to their acute care stay, they were experiencing either recent or long-term homelessness. And so this is a challenge really for the discharge planners in the nursing homes, because although they can point people to those resources that might be able to help them find shelter, the person's expectation is that the nursing home will find them shelter. So some of these resources and programs that we were exposed to as a result of our collaboration with SEP and the HUD TA program will be of great benefit to our team. As we begin to think about our work in the next program year for that particular contract.

Eric: How about you, Natalie?

Natalie: I would say that really this work together with Terri and her colleagues in health, has reinforced, for me, and I think several other folks on the team, just the interconnectedness of health and on homelessness, and really reinforce the fact that we know that people experiencing homelessness, they have their quality of life improved, they have their general sort of stability and wellbeing improved when they're able to be permanently housed. And so, recognizing that real need for housing to be at the center of the work that we're doing and recognizing that folks that are experiencing homelessness do have many vulnerabilities or challenges, that might make them much more central to public health planning as well.

I don't know that the partnerships that have been in place at the local level between public health systems and homeless response systems were there to quite the same degree that they are now due to the pandemic. So, having public health and the homeless response system really collaborating as much as possible, whether it be at the federal level, or like Terri and I did through this project together, it's really just recognizing that our work is always overlapping and intersecting, and that the more that we can center people experiencing homelessness in that work and in the responses that are developed to something like the public health crisis, the pandemic, the better that everyone will be served by that.

Eric: Well, I'm a sucker for ending the podcast whenever someone says “intersect” or “intersecting,” but it's really great that the two of you were able to partner in this way and get so much out of it, and hopefully there'll be occasion for more partnerships like this in the future. So, thank you both for joining me.