An Inter-agency approach to end deaths of homeless persons
Natalie Kroovand Hipple (1); Sarah J. M. Shaefer (2); Robert
F. Hipple, Jr. (3)
1. Indiana University, Department of Criminal Justice
2. National Fetal & Infant Mortality Review Program; American
College of Obstetricians & Gynecologists
3. Indianapolis Metropolitan Police Department
Abstract
The homeless are invisible in many communities; their deaths receive even
less attention. An inter-agency review of homeless deaths, modeled after the
Fetal and Infant Mortality Review process (FIMR), is an effective public health
approach to understanding system gaps, and providing insight into the factors resulting
in homelessness and ultimately death. This report describes the process to
develop unique police-led reviews of homeless deaths in Indianapolis, Indiana,
USA and recommendations for action to decrease these deaths. Additionally, the
police can take the lead as part of a comprehensive problem solving effort.
Introduction
The homeless are invisible in many communities; their deaths receive even
less attention. A inter-agency review of
these deaths based on the fetal and infant mortality review (FIMR) process can
provide insight into the homeless individual, system gaps that led to the
death, and ultimately change systems to prevent future deaths (Fetal and Infant Mortality Review Manual: A Guide for Communities, 2008). In Indianapolis, Indiana, USA,
law enforcement leads a team that includes community outreach workers, mental
health professionals, local hospitals, emergency medical services, probation, the
prosecutor’s office, the coroner’s office, the health department, and a local
researcher. This short report describes this innovative initiative.
Background
In January 2015, a national effort to count homeless individuals estimated
over 564,000 people nationwide were homeless on any given night. Almost
one-third of these individuals were found in locations not intended for human
habitation and 23% of the total were chronically homeless (Henry, Shivji, de Sousa, Cohen, & Abt Associates Inc., 2015). However, research suggests that the actual number of
individuals experiencing homelessness at any given time is three to five times than
this estimate (Sankari & Littlepage, 2015).
The Indianapolis Metropolitan Police Department (IMPD) took a progressive
approach to working with the homeless population in Indianapolis when it created
the Homelessness and Panhandling Unit (HPU). The HPU established cross-system
partnerships in an effort to keep homeless individuals out of the criminal
justice system and connect them with appropriate services (Hipple, 2016).
In March 2015, two fishermen found partially mummified human remains
under an Indianapolis bridge. There were indications the remains were those of
a homeless individual however no one from the HPU or its partner agencies knew
this individual even after he was positively identified. This sentinel event raised
the question, if no one from the HPU or its partner agencies had contact with
him, were there other deceased homeless individuals unknown to officials? In
fact, this event highlighted that there was no official count of homeless deaths
for Indianapolis. Therefore, IMPD sought comprehensive data on homeless deaths
which included reviewing all homeless deaths. Building on their existing
partnerships, the HPU recruited a local researcher who could help facilitate
the data collection and review process.
Incident/Death
Review Process and FIMR
IMPD was no stranger to incident reviews (Klofas et al., 2006). For law enforcement, incident reviews often
focus on specific crimes such as
homicides, however, most homeless deaths are not the result of a criminal act though
data are limited. Since homelessness is not a crime, the HPU needed to modify
their review approach, choosing a public health model, FIMR.
FIMR is an evidence-based, action-oriented community process, continually
assessing, monitoring, and working to improve service systems and community
resources for women, infants, and families (Fetal and Infant Mortality Review Manual: A Guide for Communities, 2008). This
standardized approach determines preventability, engages communities to take
action and examines various morbidities and mortalities (Koontz, Buckley, & Ruderman, 2004; McDonnell, Strobino, Baldwin,
Grason, & Misra, 2004; Nesheim et al., 2012).
The FIMR framework provides a systematic method to obtain information
about homeless deaths beyond police and outreach records. FIMR includes
consumer/family interviews to determine factors contributing to the individual’s
life and death, which yields information about environmental aspects of the
case. An inter-agency case review team (CRT) reviews each death to determine
preventability and make recommendations for system change. These
recommendations are sent to the community action team that is comprised of
community leaders with the power to implement higher level proposals and
implement recommendations. Indianapolis
partners concerned with homeless deaths supported using the FIMR process to
examine causes and preventability of homeless deaths as it added data not part
of the traditional crime incident review (Fetal and Infant Mortality Review Manual: A Guide for Communities, 2008).
Case review data also includes interviews with the deceased’s family
and/or friends. Interviews provide a consumer/family perspective on the
deceased’s situation and what may have led to homelessness and death. Data from
medical records, police reports and other sources are compared to this consumer
information. Plans are to contact neighbors and family members within one to
three weeks after notification of the death.
Homeless death reviews occur in other jurisdictions in the United States
such as Philadelphia and Sacramento although the reviews are not police-led
like in Indianapolis. IMPD also sought an independent researcher to assist with
comprehensive data collection, analysis, and facilitate the review meetings.
The HPU introduced representatives from its existing partners to the FIMR
process for reviewing homeless deaths.
Inter-agency Review
Meetings
Four goals were outlined for the reviews: prevent future deaths of
homeless individuals, create a better flow of information; compile accurate
data on homeless individual deaths; and create actionable recommendations. Prior
to the review meeting, each agency provides relevant information, such as EMS
transports, emergency department visits, medical and mental health history,
housing information, veteran status, and any other relevant details about each
decedent. A summary document for each case which was circulated. During the review
meeting, information not available from official sources, such as social
engagement, relationships, official/unofficial income is provided. This
additional information facilitates identifying service gaps while not assigning
blame. The homeless death CRT has met six times, reviewed 12 cases and has made
recommendations. Some recommendations have already been addressed by the CRT and
some recommendations need to be elevated to the community action team.
Recommendations
for Action
First, a common accidental cause of death of homeless individuals is
exposure. Indianapolis winters can be harsh. The CRT team identified protocol
modifications. Outreach workers and the HPU will be more assertive in locating
homeless individuals during cold weather emergencies. For example, looking into
tents for vulnerable individuals; prior protocol did not allow this to the
protect the homeless individual’s privacy and the outreach worker’s safety. Moreover,
part of homeless culture is ‘you are a sucker if you go in’ during extreme
weather. The team discussed ways to respectfully provide outreach including,
‘mercy arrests,’ immediate detentions, or other creative options by IMPD to
shelter vulnerable individuals temporarily and save lives.
Second, the CRT team identified the need for better coordination between
area hospitals and outreach workers. One of the large metropolitan hospitals
notifies outreach workers of homeless ‘frequent fliers.’ Outreach workers then engages
with these individuals to try and get them into services. The death reviews
revealed that this inter-agency communication between the hospital and outreach
needs to be expanded to all area hospitals located both downtown and outside of
the city center.
Third, in two cases clients agreed to go into inpatient detox but beds
were not available. One client was approved for a detox bed but one not available
immediately. That client died in the next 48 hours. Another died three days
before scheduled to enter detox. Both deaths resulted from alcohol abuse during
the waiting period. The CRT believes the deaths could have been prevented if
beds had been immediately available. This issue requires a broader community
response from the community action team.
Compiling accurate information on homeless deaths beyond those reviewed
is an important next step along with establishing the community action team.
Key to sustainability, the community action team is charged with developing
creative solutions to improve services and resources for the homeless. Also participation
is needed from the Veteran’s Administration, the health department, hospitals
and elected officials. These individuals have the resources to address the CRT
recommendations and system gaps identified in the review process. The community
action team’s sponsor should be an important lead agency in Indianapolis. For
example, in Baltimore, Maryland, the FIMR community action team is in the
Mayor’s office, providing high level visibility and access to city agencies, assuring
maximum impact.
Concluding
comments
2016 started ominously for Indianapolis’s homeless population. On January
1st, two homeless individuals died. One individual was found by a friend at a
homeless encampment and the other died at a local shelter. A total of four
homeless individuals died by January 6th. Ranked one of the ten most violent
cities in the United States in 2014 (Federal Bureau of Investigation, 2015), Indianapolis did not recorded
its first criminal homicide until January 4, 2016. Homeless individuals, while
omnipresent, are often invisible. Their deaths are no different.
Significant progress has been made and using FIMR as a public health
approach is effective. One unanticipated benefit was achieved by the CRT.
Partners were validated that in some cases, they did everything possible for
the homeless. For front line workers who often see the worst, this is affirming
and important to acknowledge.
Homelessness is a complex problem for many communities with insufficient
data. While housing is a long-term issue, preventing deaths is not. Homeless person
death reviews demonstrate there are steps that can prevent needless deaths. The
FIMR process provides an inter-agency approach to understanding system gaps with
insights into the factors that resulted in homelessness and ultimately death. It
is an innovative approach to have the police lead the way and provides a
structure for community solutions to address this public health problem.
References
Federal Bureau of Investigation. (2015). Crime in the United States, 2014. Retrieved from https://www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2012/crime-in-the-u.s.-2012/violent-crime/aggravated-assault
Fetal and Infant
Mortality Review Manual: A Guide for Communities. (2008). (2nd ed.). Washington, DC: American College
of Obstetricians and Gynecologists.
Henry, M., Shivji,
A., de Sousa, T., Cohen, R., & Abt Associates Inc. (2015). The 2015 Annual Homeless Assessment Report
(AHAR) to Congress: Point-in-Time estimates of homelessness. Retrieved from
Washington, DC:
Hipple, N. K. (2016).
Policing and homelessness: Using partnerships to address a cross system issue. Policing: A Journal of Policy and Practice.
doi:doi:10.1093/police/paw010
Klofas, J. M.,
Hipple, N. K., McDevitt, J., Bynum, T. S., McGarrell, E. F., & Decker, S.
H. (2006). Project Safe Neighborhoods: Strategic interventions crime incident
reviews: Case Study 3 Project Safe
Neighborhoods: Strategic Interventions. Washington, DC: U.S. Department of
Justice, Office of Justice Programs.
Koontz, A. M.,
Buckley, K. A., & Ruderman, M. (2004). The evolution of fetal and infant
mortality review as a public health strategy. Maternal and child health journal, 8(4), 195-203.
doi:10.1023/B:MACI.0000047418.14086.fc
McDonnell, K. A.,
Strobino, D. M., Baldwin, K. M., Grason, H., & Misra, D. P. (2004).
Comparison of FIMR programs with other perinatal systems initiatives. Maternal & Child Health Journal, 8(4),
231-238.
Nesheim, S., Taylor,
A., Lampe, M. A., Kilmarx, P. H., Fitz Harris, L., Whitmore, S., . . . Mermin,
J. (2012). A Framework for elimination of perinatal transmission of HIV in the
United States. Pediatrics, 130(4),
738-744. doi:10.1542/peds.2012-0194
Sankari, A., &
Littlepage, L. (2015). Many Families in
Indiana Not Able to Find Shelter. Indianapolis, IN: Indiana University
Public Policy Institute.
