Being Community: HealthBridge

While Micah works toward Jeremiah Community, a place where neighbors can live affordably, have purpose and grow meaningful relationships, consider the many ways our collaboration of churches have already built a neighborhood of scattered parts.

Early one morning, I wandered into Market Square on a tip that some of our neighbors had been bedding down for the night.

With a backpack for a pillow, a couple of guys occupied the benches around the perimeter. I looked carefully and quietly, only to see who they were but not awaken them. Their blankets swaddled so tightly around their bodies and covered their heads that the only evidence of human life were the boots that emerged from the bottom.

In a nearby corner, a fellow that I knew was heating up his coffee on a campfire stove and chatting away with a young man who was already awake.

“Would you all happen to know who is sleeping there?” I asked. They proceeded to share the identifying information that I needed in order to connect with the sleepers at a later time.

“And how about you all?” I asked. “What can I do to help you get out of this situation?”

“I need a pair of shoes,” the young man replied. “I’m having a problem with my feet. They hurt so bad, it’s keeping me from working.”

Some months later, after three or four different kinds of shoes of varied sizes, the friend I met that morning in market square had the opportunity to check out his foot problem with a local doctor who had started medical outreach at the Micah Hospitality Center. It turned out a lot more than shoes were available to treat the condition that was keeping him out of work.

Connection to adaptive equipment, referrals for lab work, physical therapy, x-rays or home health, and addressing immediate medication needs are just some of the supports that have come available through Micah’s newest initiative called HealthBridge.

“Many of our neighbors have no primary care,” said Teresa Bowers, program coordinator. “This leads them to chronic use of the emergency room or urgent care; and sometimes they don’t even address what can be a serious health condition.”

HealthBridge aims to recruit local medical and mental health service providers who are willing to provide assistance to unhoused neighbors at the Micah Hospitality Center or, in some cases, in their home. Providers may be volunteer or contracted for service. The project was funded earlier this year by an innovation grant from the Virginia Department of Housing and Community Development, aimed at building up capacity to support vulnerable people in housing.

Even though many are now covered by Medicaid or Medicare, unhoused neighbors are easily frustrated by long waits and complicated processes required to access care. They are poor self-advocates and often mistrust organized systems. Years of rough-living on the street catches up with people, even in housing. As health declines, neighbors who have experienced homelessness often lack family supports that most frequently supplement obvious health solutions.

Streamlining partnerships with the health community, therefore, encourages medical and mental health providers to meet people where they are in their health journey, understand their needs, provide resources and help them figure out an effective plan of care.

Dr Theron Stinar, from Fredericksburg Christian Health Center, has been the inaugural partner for the HealthBridge initiative. He sees patients at the hospitality center or in their home every other week for about four hours.

He comes alongside a long-standing partnership with the Germanna Nursing Students, who provide health screenings and education from the hospitality center once a week during the school year. Several other local doctors will engage with the program in the fall; and we continue to seek other innovative ways to meet the healthcare needs of our neighbors.

Assistance is provided from a central location. It often focuses on immediate needs, answering questions and building trusting relationships. HealthBridge is not an effort to provide community-based primary care, rather it is a “bridge” for people who are accustomed to addressing needs on a survival basis to engage with more comprehensive systems of care.

“We are helping neighbors who don’t already have an established health care provider,” Bowers said.

HealthBridge is currently following approximately 25 people, and is gaining 4-5 new patients every couple of weeks. Most have been utilizing the emergency room an average of nine times a year. Over time, the program hopes to demonstrate that HealthBridge patients make less use of the emergency room and engage more fully with coordinated care systems, which also provide a cost savings for the community.

Some of the major wins, thus far, have included patients who gained immediate referrals to X-rays and been able to come back to the Hospitality Center for results and care coordination. HealthBridge is currently facilitating a hernia repair, cancer screening and Hepatitis C treatment for some of our neighbors. People who have been off medication for some time have been able to get started again after seeing a doctor at the day center. The program has also allowed neighbors with mental health needs to start medication and begin the journey to stability. Based on relationships formed through HealthBridge, many neighbors have chosen to schedule follow ups at a provider’s office and kept their appointments.

In the coming months, Micah hopes to expand upon connections to psychiatric and counseling services, as well as home health supports, medication management and nurse case management.

~Meghann Cotter