‘This is Public Health in Action’.

Megan Williams SPH'02 and Director of Nursing at Clare Housing

Breakfast: Coffee, first and foremost, and then a power breakfast bowl with brown rice, black beans, egg, avocado, queso blanc and hot sauce..

Hometown: Minneapolis, Minnesota.

Extracurriculars: Yoga, barre, traveling, and hanging with my hubby and kids.

Can you describe the mission of Clare Housing and the population you serve?

Clare Housing is a nonprofit organization with a mission to provide housing and health care to people who are living with HIV/AIDS. We are the only HIV-specific permanent housing in Minnesota. The Clare Housing mantra isx “housing = health care.” Given my public health background and clinical experience working for a county hospital as a nurse in a medical intensive care unit, this really resonated with me. At the county hospital, we served underserved communities, many of whom lacked housing. Clare Housing originally provided end-of-life care 30 years ago when people were dying from AIDS. Then, with the advent of anti-retroviral medications, it shifted into housing because people were living longer but still needed support. We also saw the epidemic shift slightly and target a demographic of people who were disenfranchised and in impoverished communities.

We serve clients from 18 to 65-plus years old. The mean age range is 46 to 55 years old. We have four support housing apartment buildings and four adult foster homes for more physically disabled individuals, and a scattered site program. The average length of stay is five years, but the length of stay in the foster care homes tends to be longer, so some people have been here for 15 years. Ninety percent of the people we serve are virally suppressed.

We are seeing an uptick in the epidemic now, as new infections are occurring in MSM African American, and Latino as well as Caucasian men between the ages of 18 to 25. Many of these young men struggle with mental health issues, stigma, trauma, and addiction, especially to methamphetamines. With these struggles, it takes creativity and trust in order to keep them housed. We’re also seeing an increase in the need for housing and care for the 55-plus age range, as our longterm survivors have been HIV-positive for more than 25 years.

What are your responsibilities as director of nursing?

As the director of nursing, I manage five nurses and provide direction to 10 residents assistants. I also provide oversight and direction for 40 clients’ individualized care plans. I make sure we are following our comprehensive home care license requirements and that every plan we have for our clients is being met. Our part of the organization’s leadership team, and provide input into new programming, and organizational direction. Annually, we collect data on various health outcomes to identify trends, improvements, and gaps in services. We are particularly interested in looking at the change in viral load after one year of housing stability.

What are some of the unique challenges that clients face before and after they arrive at Clare?

The majority of the people we serve have longterm issues with trauma, generational poverty, institutional racism shame, trust, and stigma. A lot of our clients come from the streets, from a shelter, or from a nursing home. Eighty-two percent of our population experiences homelessness before coming here. For people who are homeless and HIV-positive, medication adherence is really hard, and antiviral medications have to be taken every day. People living in shelters have a hard time getting their medications filled. They also hide their medications because of theft issues. Another struggle is getting to healthcare appointments.

In addition to getting our clients stabilized with HIV medications, they also deal with chronic illnesses, mental health, and addiction issues. Cardiovascular disease and diabetes are accelerated when you’re HIV-positive, due to chronic inflammation. Mental health and substance abuse have created a lot of barriers for clients maintaining housing. We take a lot of people with criminal backgrounds—as a lot of other agencies do not—and we provide permanent housing, as opposed to temporary housing. Fifty percent of our clients have a mental health diagnosis and a chemical addiction diagnosis, and about 40 percent have a gross misdemeanor or felony before coming to Clare. We embrace and utilize two models: housing first and harm reduction. It’s about getting people in to housing without any barriers, and then connecting them to services once they’re stable.

This is public health in action. When clients are housed and have undetectable viral loads, they cannot pass on the virus. This reduces the community viral load and saves counties and states money by decreasing frequent emergency department visits.

What types of backgrounds do your nurses have?

The nurses that are attracted to this job are people who have public health backgrounds. A lot of our nurses have a background in mental health. Because of the way our licensing is categorized, we fall into senior care, so I have a lot of nurses who have worked in assisted living. We look for people who can empathize with this population and who are relatable to our clients. We’re low-key in terms of dress and attire – my nurses don’t wear scrubs, they just wear everyday clothes. You have to take a certain amount of time building trust, because these individuals have had so many negative experiences with the healthcare system and with the general population.

The hardest thing for nurses working in public health, as opposed to a clinical setting, is that you have no control over the environment. When you’re in the community, you have to rely on your skills as a nurse, the team that you have around you, and the community responders.

We do a lot of end-of-life care here as well. The client has the right to refuse medication, or choose to stop going to dialysis, and all we can do is provide them with the education about what’s going to happen to them, and make sure we’re connecting to their providers. We have to have this mind shift, and be able to go from a curative role to an educational and supportive role, knowing that we have no control over the outcome.

How do the responsibilities of public health nurses compare to nurses in clinical settings?

If you’re in community or public health nursing, you’re supposed to be the coordinator of care. You have to be able to do a lot of social services work, because if a social worker is out, a lot of the responsibilities fall to the nurse. Sometimes, it’s just that we have better relationships with the clients. As much as we try to protect ourselves and put boundaries up—not because we don’t want to help them, but that you need to do that in order to survive and not get burnt out—more and more nurses are taking on multiple roles. We really are the first line. We literally live with our clients, so we can see health issues coming faster than their clinic team.

There is a lot of value in the trust that I’ve built with my clients. This is the longest job that I’ve had, and I feel so honored that I’ve been able to do this this type of work. I just love serving this population, and I can’t really imagine doing anything else. This is where I’m supposed to be.

—Jillian McKoy