Providing Health Care for the Homeless: A Look Back at the Roots of a Novel Initiative

As city leaders grapple with the latest attempt to help homeless New Yorkers with serious mental illness, it’s worth looking back on an earlier initiative to care for some of the city’s most vulnerable citizens. 

Mayor Eric Adams’ new directive—to involuntarily hospitalize New Yorkers who are mentally ill, unsheltered, and deemed unable to care for themselves—comes 37 years after perhaps one of the first efforts to bring health care to those living on the streets. 

Back then, in 1985, United Hospital Fund helped establish Health Care for the Homeless (now operating as Care for the Homeless) after a request from the New York City Human Resources Administration (HRA), which oversees services to the city’s homeless population.  

Among the first homeless health care organizations in the country, the coalition was particularly novel at the time. Before its existence, community advocates and public officials often only saw one another when contention over policies toward the homeless brought them both to court. 

But when the Robert Wood Johnson Foundation and the Pew Charitable Trusts invited 51 cities to apply for grant funds to improve health care for the homeless, the benefits of cooperation suddenly became apparent. 

United Hospital Fund, at the request of HRA, brought together local health care and social service providers, city and state agencies, and voluntary and religious organizations to develop a proposal.  

“The Fund was viewed as a neutral party driven only by its commitment to health care,” Susan Neibacher, who was Care for the Homeless’ first executive director until her death in 2004, recalled in a previous UHF profile of the organization. 

A successful exercise three decades ago, the need for this cooperation still exists today.  

As UHF president and CEO Oxiris Barbot, MD, writes, “strong partnerships between community organizations, hospitals, and government agencies can deliver effective housing, services, and health care to our fellow New Yorkers, keeping them off the streets and out of the emergency room or psychiatric unit.” 

When people do end up in a hospital bed, there is an obligation to ensure that each patient has a “warm handoff” to a community organization or service provider. This should be accompanied by a comprehensive plan that keeps them off the street and continues to provide them with the medications and health care they need, rather than ushering them into an endless cycle of street, jail or hospital, and street again, Barbot adds. 

In 1985, the UHF-led coalition agreed on a program to deliver basic health care services in soup kitchens, shelters, drop-in programs, and other places where homeless people congregate. Once its grant application was approved, UHF administered the project, contracting with two freestanding health centers and one teaching hospital to bring in teams of medical and social service providers. 

Just as they are now, the challenges facing these teams were complicated and went beyond traditional clinical care. To succeed, the coalition’s interdisciplinary care teams had to offer more than medical care—they also had to build trust, expedite access to Medicaid, and address a host of interrelated social service needs. 

Care for the Homeless became an independent organization in 1992. Today, with a more than $30 million budget, a 243-person staff, and a mix of public and private grants and contracts, it provides more than 33,000 visits to patients each year at its 26 sites across the five boroughs. 

“One of the primary reasons little to no progress has been made in caring for people who are both homeless and mentally ill is that we delay action until they are already in very dire straits, rather than keeping them from getting so sick to begin with,” Barbot writes. “Prevention may sound like an expensive proposition, but in fact there are plenty of effective actions we can do with the funds we already have, and it would save money in the long run.”