With a mission to reduce the need and cost of care for people from all segments of Kansas City’s homeless population, the BE THE CHANGE Program facilitates the path off the street by helping people identify and access available resources, by filling gaps with support throughout the process and by collaboratively addressing individual and systemic challenges to improve the collective impact of Kansas City’s safety net. The BE THE CHANGE Programs tailors its services to the needs of the individual, offering a diverse menu of services directly or through an extensive collaborative network. That can take many forms, including: A single ride to a medical, legal or housing appointment for women in a domestic violence or family shelter. A Sunday night meal in the park to maintain contact and build rapport so individuals will call when they are ready to make a change. Arranging shelter and transporting a newly homeless person, following up with them to plan and assist with their next steps. Arranging lodging, food and transportation on for a stranded traveler. Meeting with a person being discharged from a hospital or jail to assess their needs and make individual plans, arrange housing or treatment programs, assist with ID’s, medication or supplies necessary for admission, transporting them and then follow-up meetings and services to assure adherence with treatment or parole requirements. Providing respite housing at Bodhi House that allows residents to continue to progress without having to return to the street while on wait lists for housing or treatment. Rapidly responding to and arranging services for an individual that has relapsed to minimize the impact and recovery time. Providing a clean and sober apartment at Finnegan Place with peer support for those in the final stages of reintegration. Intensive care coordination and advocacy, usually for chronic homeless and young adults alienated from family and the agencies that could help them, as they progress from agency to agency to provide support, consistency and focus. Follow up meetings, often in facilities of collaborating agencies, foster client engagement and allow plans to be adjusted with developments. Success is measured one person at a time. Through deed and example, the program strives to provide aid with respect, address underlying issues, and work with, rather than duplicate existing services. Helping people get off the street reduces the cost for care by reducing their exposure to the chaos of life on the street and their reliance on emergency and social services. Ultimately, the program strives to not only reduce its clients’ reliance on society, but to help its clients become contributing members of society.Program benefits are realized long before individuals successfully reintegrate. Cost of care is further reduced by the program improving outcomes and efficiency for both its homeless clients and the agencies that serve them. By coordinating care, the program reduces fragmentation and duplication. By filling gaps, it improves adherence to treatment plans, reduces recidivism and promotes integrated, preventive care. The program also has an impact of the local safety net and our community. By drawing together services of agencies limited by geographical, financial or cultural constraints, the program improves the collective impact of the safety net. By filling gaps, fewer people fall through the cracks. Outcomes and efficiency improve. By creating innovative solutions to safety net challenges, agencies can achieve more with the limited available resources.
The BE THE CHANGE Program was created as a transportation based hospital diversion program. The scope and nature of the program grew organically as the program staff learned the stories, aims and challenges of riders. A 2013 study by a Kansas City University of Medicine and Biosciences team was instrumental in identifying the emerging methods and strategies. 1. Improve the collective impact of the local safety net. Recognizing resources to address homeless issues are limited, the program strives to improve outcomes and efficiency of its homeless clients and the agencies that serve them. Removing barriers and filling gaps improve coordination of services and reduce relapse and recidivism. The program’s innovate longitudinal approach improves communication and client engagement as they progress from agency to agency, case worker to case worker. 2. Intensive street outreach. Recognizing that transportation is a significant barrier for the homeless, the program meets clients where they are rather than making them come to us. A true collaboration, it usually meets clients in facilities of other agencies --- hospitals, shelters, detox, homeless and recovery programs, transitional living facilities, courts, jails, public buildings and businesses. This presence builds trust and approachability with clients. At the same time, it allows program staff to understand the programs, capabilities and challenges of collaborating agencies. 3. Work with, rather than duplicate existing services. Recognizing Kansas City has many capable local agencies providing quality specialized services to the homeless, the program created a true collaboration of diverse agencies to provide clients a wide menu of services to address the issues that led to or resulted from being homeless. The program fosters coordination and communication between agencies that are frequently restricted by geographical, financial or corporate parameters in order to identify and address individual and systemic challenges. 4. Use a longitudinal approach to address underlying issues. Recognizing that when a service continuum contains significant gaps in either scope or process, individuals fall in and out of services; the program works with clients as they progress from agency to agency in a true continuum of care. It provides support, identifies and fills gaps and adjusts individual plans for developments. This longitudinal approach allows multiple issues to be addressed concurrently, as well as fostering consistency, client engagement and focus. The KCUMB study found “intensive collaboration afforded to individuals seeking services by AHH appears to improve their likelihood of success.” 5. Not facility based. Recognizing no two client’s stories, needs and challenges are the same, the program starts with the individual and creatively tailors plans without prefabricated goals, strategies, endpoints or measurements. This approach allows staff to draw upon a wide menu of services of collaborating agencies to draw upon the individual’s strengths. AHH has no “office” but through technology operates where the client is. The two facilities it operates fill gaps in the safety net for a small (7%) portion of clients, but ones who have relied heavily on local services. 6. Provide aid with respect. Recognizing the homeless are generally a distrusting population, the program meets people where they are, literally and figuratively, which builds trust and rapport. Some clients, especially the chronic homeless and alienated young adults, have been banned from one or more agencies that could help them. The KCUMB team noted, “While [AHH] maintain limits and impose consequence, problems are handled less with operational mechanisms and non-negotiable, algorithmic outcomes, but through narrative discourse, where rule violations and behavioral problems are treated as opportunities for discussion and guidance.”
The prior section outlined how the BE THE CHANGE Program improves the collective impact of Kansas City’s safety net. Taking a collective impact approach, looking at the problem from the perspective of the entire safety net sets AHH apart and uniquely enables it to progress toward its mission. Safety Net Perspective: AHH’s wider perspective on this community challenge has been attributed to Woo combining an artist’s sensibility with a business practicality. Commissioned to create a program to reduce reliance of the homeless on EDs, he had a blank canvas. But he realize the challenge was city-wide. The solution would require drawing on resources from across the city. It only made sense to utilized available resources. But, as the KCUMB study later observed, “Homeless service agencies often operate in silos, or collaborate only with a limited pipeline of other agencies,” Looking at the big picture, it was clear filling the gaps would improve outcomes and efficiency for everyone. The program’s innovative longitudinal approach evolved. Targeted Initiatives: Program initiatives target systemic challenges for specific segments of the local homeless population. Most result from and involve collaborations with existing agencies. To address challenges of long-term homeless person with disabilities, chronic illnesses and mental health issues, the Save Our Seniors initiative worked with area nursing homes and other agencies to qualify and secure placement. When individuals completed recovery and reintegrated, only to struggle due to limited peer support or financial resources, Finnegan Place was created. The KCUMB study noted AHH’s “ability to expand [its scope of service] is significantly bolstered by the fact that there are few constraints on what sorts of services they can deliver.” Extensive Collaboration: As the BE THE CHANGE Program improved outcomes and efficiency of clients, other agencies benefited. Initially, collaboration involved specific clients referred by or to AHH with AHH invited to work with these clients in the agency's facilities. The expanding needs of clients brought other agencies on board. Today the program offers clients a wide menu of services through its network of collaborating services that includes over three dozen medical and mental health hospitals, homeless shelters and services, recovery and treatment programs, transitional housing facilities, the court system, legal services and jails. These agencies have also provided AHH staff training, in kind support and helped staff and equip the medical and dental clinic. Staff Cultural Competence: As a foreign student, Woo had to ask many questions to understand terms his classmates and professors used. While working and going to school, a fire at his apartment building left him homeless. Those experiences as an outsider, being homeless were the seeds of understanding and empathy seen in AHH programs. Most AHH employees have been on the street, through recovery and alienated at one time from family and society. They can relate to their homeless clients with first hand experiences. The KCUMB study reported “many of the people we spoke with, both clients of AHH and other service agency workers, noted that the relationship that AHH has with those they serve is exceptionally good.” Mutual Value: In 2014, a major urban core hospital attributed a $1,700,000 savings in homeless ED cases to the program. A mental health hospital reported that homeless patients released to the BE THE CHANGE Program had a recidivism rate one-third that of others. Homeless and recovery agencies routinely call the program to assistance with discharge plans, often for their more challenging clients. The KCUMB study found the program “functions to coordinate many existing services, bolstering their efficacy.” One research team member likened the program to “hemoglobin in the blood, making sure oxygen gets where it needs to go.”
The BE THE CHANGE Program targets three distinct beneficiaries: the homeless, the agencies that serve them and our community. Results are measured in terms of program/initiative outputs, individual and program outcomes and resolution of systemic issues. Homeless: Services to clients are tracked individually and periodically summarized. The resulting data provides both client status and history which is used in adjusting individual plans. It allows clients to be matched with agencies that match their specific needs. The programs extensive outreach presence results in it encountering clients especially if they have encountered difficulty. The program is frequently called upon by clients when they encounter challenges, sometimes long after services have been provided. For clients receiving basic services that are one time or short duration, this data is used to evaluate usage (need) and methods. For more extensive care coordination, the program’s longitudinal approach involves ongoing engagement as client progress. The data is also used to monitor programs and initiatives. It is also used to evaluate and adjust programming. Monitoring the rate of residents moving on to treatment, housing or other programs demonstrates the effectiveness of Bodhi House and Finnegan Place. another example is the creation and evaluation the medical and dental clinic there. Clients and agencies provide anecdotal evidence such as a note left on the van’s windshield that read, “Thank you. You helped my family and me. We’re doing great now.” Or the social worker who told the KCUMB team, “he’s truly meeting the needs of individuals that really need it…” Agencies: Client data provide an indication of referrals to and from other agencies which is used to evaluate programming. The program uses costing from a 2009 KCMO Police Department presentation to estimate the program’s impact to local emergency services. The estimate is conservative because it does not factor in the savings of individuals being off the street for extended periods. Still this measure indicates the program saves over $5 for each $1 invested. That, and the savings from the urban core hospital reported above indicate the program is achieving its primary objective. The program’s benefit to other agencies can be also measured by organizations seeking to partner with it or to extend its principles to new applications. In 2017, the KCMO Police Department asked AHH to assist them in dismantling a homeless camp while assuring residents received the help they needed. Recently, the City of Lawrence/Douglas County consulted with AHH regarding their efforts to look outside the box on addressing homeless issues there. Safety Net: Summarizing the individual data provides insight into how the program impacts the safety net. Perhaps the best example is found tracking results of the initiatives designed to address systemic issues. For example, the Save Our Seniors program has placed over 150 individuals in nursing facilities. About 7½% moved to other housing with a similar portion returning to the street. The reliance on local emergency services was substantially reduced when these clients realize better nutrition, better hygiene and better access to health care while avoiding the perils and conditions of life on the street.
Artists Helping the homeless was started in 2008 to fund a
Sunday meal for 20 homeless people in a midtown park, now routinely feeds 60-100 people with second meal serving 250-300. The BE THE CHANGE Program, started as a transportation based hospital diversion program in 2010, now serves over 2,600 people annually. A unique, longitudinal client-centered approach developed resulting in the program being dubbed “the safety net for the safety net”. A true collaboration was created that has improved the collective impact of the local homeless services safety net and earned the Excellence in Collaboration Award of NonProfit Connect (2017). Innovative initiatives like Save Our Seniors and the Justice Initiative address individual and systemic issues. Bodhi House and Finnegan Place offer the chronically homeless, alienated young adults and others who relied heavily on emergency services housing so they can pursue education, employment and independence. A new medical and dental clinic fills yet another gap to reduce reliance on local emergency services. Since its inception, the program has assisted over 15,000 people including over several hundred chronic homeless and alienated young adults place in transitional and long-term housing. As a result, local community emergency services have save tens of millions of dollars. That is significant. But for the program, the scared, withdrawn young man that is now employed and attending a university with plans for a medical career; the once homeless man recently recognized by his employer as one of their top fifteen employees nationwide; the emaciated young man met in the hospital fighting the consequences of substance issues who is now employed and living independently are the true measures of success. Lessons can easily be drawn from these accomplishments. But not all storied end well. Several clients successfully navigated recovery and reintegration only to withdraw or relapse. Their experiences led to creation of a new type of transitional living, Finnegan Place which is still a work in progress. These stories also highlight challenges the program faces. The longitudinal approach can be resource intensive. At any point in time, the active intensive care coordination clientele numbers 150-200. That does not include the ongoing requests from clients that have reintegrated. This approach requires staff to empathize, yet be able to partition the work from themselves. While this is not a 9-5 job, it does offer the satisfaction of seeing the growth described in the stories above. AHH must expand its small, dedicated staff. The ever changing environment is another challenge. Economic developments and governmental budget priorities both nationally and across state lines impact funding and services which reduces or increases the number of homeless as well as the nature and extent of services available to address this challenge. The BE THE CHANGE Program was created to address the challenge of ACA provisions and Medicaid not being expanded locally. When funding resulted in the loss of detox and inpatient treatment beds locally, Bodhi House was opened to fill the gap during longer wait times. The entry of new illicit drugs adds to that challenge. The program works with community agencies directly impacted to mitigate the effects of the changing environment. The greatest lesson learned is caring counts. A common comment of successful clients is “you believed in me when no one else, not even me, did.” The program doesn’t change people, only they can do that. The program removes barriers, provides examples and support to facilitate that change. Another lesson learned is that working together, more can be accomplished. The program facilitates coordination and communication between agencies with common goals separated by state lines and other boundaries.The Program embodies its motto: Helping the Homeless, Helping the Community