Care for the Vulnerable

Care for the Vulnerable

Until we integrate America's traditionally separate services for health care, housing, social support, and juvenile justice, we won't be able to meet the needs of millions in our society.

If you work on the front lines of America’s health care crisis, you know that a lack of medical insurance is just part of the problem. Even with universal coverage, millions of people still won’t receive the care they need.

How can you help a child with asthma whose mother is addicted to drugs and keeps missing appointments? What do you do about a person with schizophrenia, diabetes, and heart disease who doesn’t take his medication? How can you provide quality health care to a family living in a homeless shelter?

These individuals and families need intensive medical, mental health, and social-support services, but they fall through the cracks of today’s health care delivery system. Public health experts like Kyle L. Grazier, a professor of health management and policy in the School of Public Health, call them vulnerable populations. They suffer physically, socially, and financially.

Grazier says society also pays a high price for failing to care for vulnerable populations. Untreated addiction often leads to drunk driving, suicide, broken families, and juvenile delinquency. Lack of transitional housing and job training programs brings more homelessness and crime.

Public and private agencies and other groups have been trying since the 1960s to develop programs with integrated medical, substance-abuse, and social-support services to handle the complex needs of vulnerable populations. But restricted funding sources, legal barriers, and specialized service providers have made it difficult, if not impossible.

With support from the Robert Wood Johnson Foundation, Grazier has spent two years interviewing over 300 individuals nationwide who affect and are affected by the currently separate systems. She intensively studied some of the programs around the country that have found a way to make it work—programs that are providing high-quality care to vulnerable children and adults dealing with mental illness, addiction, juvenile detention, homelessness, and other issues.

The programs Grazier discovered are different on many levels. Some are rural; some are urban. Some are informal organizations relying on volunteers; others are part of county or state public health agencies with physicians, psychologists, and social workers on staff.

“The goal of the study was to identify the essential ingredients for a successful program,” says Grazier. “Given that these places are so different, what is it that makes them successful?”

The first, and Grazier believes most important, factor behind each program’s success is personal and intangible. “Somebody has to have this incredible vision—enough of a vision that people are willing to work until it gets accomplished,” she says.

Money is also crucial, but Grazier’s research suggests it’s not the amount of money, but the way finances are organized that is most important. Another factor is the willingness of providers to work together and do whatever it takes to get people the services they need. If a client needs to attend AA meetings, but has no transportation, someone will provide taxi vouchers and call every day to make sure they show up.

Grazier says her work for the RWJ Foundation makes her optimistic that it is possible to provide quality integrated care for vulnerable populations. “I’ve seen it work under so many different conditions,” she says. “We can learn from them.”

By Sally Pobojewski

Hard Times Hurt

Historically, economic crises such as the one we are experiencing have led to spikes in mental health disorders, including higher rates of suicide and a greater number of hospitalizations. That’s what Kara Zivin and Sandro Galea have found in a review of population studies in the U.S. and abroad, dating back to the late-19th century.

Zivin, a research investigator at the Department of Veterans Affairs and an assistant professor in the UM Department of Psychiatry, and Galea, a former professor of epidemiology at UM SPH, conducted a review of research studies that looked at how economic downturns—as determined by rising unemployment rates—have affected population mental health. They view their study as a good way of “getting a start on what we do and don’t know” about the effect of economic downturns on human mental health.

Going back to the early 20th century, Zivin says, scientists were interested in understanding whether economic downturns led to an increase in suicides and hospitalizations. Their survey suggests that the answer is yes; they anticipate that the current crisis will have a similarly adverse effect on mental health.

How Bad?

With an unemployment rate of 15.2 percent—the highest in the U.S.—Michigan is a poster child for the global recession. Since 2007, hundreds of thousands of Michigan workers have lost their jobs, homes, medical insurance, and pensions as businesses either shut down or laid off most of its employees. The economic effects of the recession are obvious, but what are the consequences for people’s health—especially in a state like Michigan with a long history of racial disparities in health and access to medical care?

To find out, Sarah Burgard, an assistant professor of epidemiology at UM SPH,, is working with colleagues in the UM’s School of Public Policy and the Institute for Social Research to conduct a 3-year survey of 1,000 white and African-American families living in the Detroit area.

A secondary goal of the study is to determine whether support programs—such as tax credits, food stamp assistance, and extended unemployment benefits—included in the 2009 Ameri-can Reinvestment and Recovery Act really helped people affected by the recession.

“It’s the first panel study to be conducted in the field during this recession to see how people are coping,” says Burgard. “We are trying to understand how these families are being affected and the best ways to help people deal with it.