Flagstaff’s Housing as Healthcare program is continuing to connect people with resources to improve their health and housing needs. The program is a partnership between North Country Healthcare (NCHC), Flagstaff Shelter Services (FSS) and other community organizations, and it works to improve both areas by working on them in a more connected way.

The program has “proven to be one of the most important investments of our time and energy and resources in light of the pandemic,” said Ross Altenbaugh, FSS’s executive director.

The connection between housing and healthcare is in “all those little things,” said Bridget Wicks, a family nurse practitioner with NCHC: reduced barriers to transportation, the ability to prepare and store meals to meet specific nutritional needs, a sense of stability that can lead to improvements in a number of health-related areas.

Housing as Healthcare

Ed Kohl steps into a mobile medical clinic from North Country Healthcare at Flagstaff Shelter Services Thursday morning. Kohl was getting his medications refilled.

“In America, we have this traditional viewpoint that you don’t deserve housing if you have a substance abuse problem or if you’re unemployed because of the perception that you’re not trying hard enough,” she said. “A lot of studies have proven that once people get housing and they have an address, they’re able to sleep well, substance abuse reduces, employment goes up, personal responsibility improves.”

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The program is a set of interconnected programs and services focusing on three tiers of connected needs: physical health, behavioral health and housing.

Wicks visits FSS twice a week with a mobile medical unit, for example, as making it to appointments on time can be difficult without reliable transportation. The units are “a way to bring healthcare where people are living,” said NCHC CEO Anne Newland.

“We bring the care to them to meet them where they’re at and then that allows them to focus on themselves to get housing and get employment,” Wicks said.

The program uses a national-best practice standard known as a housing first model. The idea is that the best way to deal with the issue is to get people into housing and provide the background services they need to stay housed.

Altenbaugh called the model “extremely effective” in getting people into shelter and keeping them there.

FSS uses the model with almost everyone coming through the shelter.

The majority are able to stay permanently housed once they’ve been housed initially, and it’s more cost effective than having them stay in a shelter, she said. The program was one of the Health First Foundation’s Community Health Grant recipients in 2021 and most of that funding went to housing, according to Altenbaugh.

“We’re really trying to put resources at the base level of what people need and then come in with extra resources as they need them,” she said. “So it helps pay for things like first month’s rent and a security deposit, the case management support that they need to be able to keep that housing as well as things like transportation and connecting people to any kind of job needs they might have — that kind of thing.”

Yes, I Will Go

Richard Brown had his left leg amputated below the knee and all five toes of his right foot amputated in February after passing out during a storm. Staff at Flagstaff Shelter Services found him and transported him to the shelter, and realized that he had exposure injuries. So they took him directly to North Country Healthcare, which diagnosed severe frostbite. Brown was then taken to the emergency room and admitted to Flagstaff Medical Center. Discharging himself from the hospital and struggling to heal, Brown was seen during a followup appointment with North Country Healthcare at Flagstaff Shelter Services. He agreed to go to a skilled nursing center once staff could secure him a place. He is an example of the multi-agency Housing as Healthcare program working to support those in the community facing homelessness.

There is a plan in place to shift full responsibility for rent and utilities to clients in this program — which Wicks said was a common misconception.

“It’s not that people are getting free service and that they don’t pay,” she said. “…They really do become responsible and contribute back to the community. I just think that people need to know that individuals work very, very hard to get this housing. They’re incredibly proud of themselves, and it really is a successful journey when they do get housing.”

Her involvement in this program is “by far my favorite job that I’ve done in healthcare,” Wicks said. “…It’s just so exciting when somebody gets housing. It’s this celebration because of the difference it can make in their lives.”

She described the mobile medical unit as “like a traveling little clinic,” which visits the shelter and other locations around Flagstaff. It’s a sprinter van, with an exam table and a variety of other equipment — emergency response jump kits, AEDs, wound care supplies, hygiene products, reading glasses.

The mobile unit functions as a primary care clinic, providing primary and acute care, vaccinations, testing and delivering medication. Staff can order lab work and X-rays, refer patients to specialists and transport them to certain appointments.

Behavioral health professionals, family health advocate and clinical pharmacist are also often there to help access things such as insurance and food stamps and fill prescriptions as needed.

“Having health insurance opens the doors to getting all kinds of care,” Newland said. “You can get your prescriptions paid for, your medications. You can see a doctor, and insurance will pay for that visit.”

Patients can sign up for appointments on a walk-up basis whenever the unit visits. It is all done on a sliding scale, so no one will be turned away based on their ability to pay.

“We help them with harm reduction, and try to keep them motivated in their personal health and wellness. It provides a good grounding point for them that somebody is caring for them and looking out for them as individuals. Our healthcare system can be really hard for people with a lot of social determinants of health,” Wicks said. “Once we can bridge all of that, we can help them connect into services.”

She said the goal of the mobile units is to improve community health as well as on an individual level. Visits help reduce the use of emergency rooms as primary care providers, for example. Knowing when the mobile unit is showing up makes it easier to wait. 

Mobile unit staff are also involved in connecting people to housing resources.

Wicks said the main growth she’s seen in the program since it started has been in its outreach — identifying individuals who may benefit and seeking them out to let them know about it.

“I tend to see people a little more frequently so that way we can have an open conversation and remind them of appointment times and that type of thing and help them stay motivated, and we give consistent messaging to try to help people, because [finding housing] can get real frustrating in Flagstaff,” Wicks said.

Both Wicks and Altenbaugh said their hope for the program is that it would continue to grow and be a model for other efforts in northern Arizona.

“I think it’s a model for how we should be delivering healthcare to high-need populations, and people experiencing homelessness are a special population. It’s how you braid together the physical health needs and the behavioral health needs and address housing all at once. Because if we just address one piece of those things, we’re not really supporting the client or the patient adequately,” Newland said. “Having those doors open between all of our organizations and working collaboratively, I feel like it’s just a great model for us to end homelessness in northern Arizona.”

Wound Care

Richard Brown had his left leg amputated below the knee and all five toes of his right foot amputated in February after passing out during a storm.