A randomised trial of compassionate care for the homeless in an emergency department

"The team needs to feel cared for": staff perceptions of compassionate care, aids and barriers in adolescent mental health wards

Background

Compassion is vital in healthcare. Current understandings of the nature of compassionate care, its aids and barriers, are more theoretically developed than grounded in staff experience. This study explores staff perceptions of compassionate care in child and adolescent mental health wards.

Methods

Three focus groups were conducted with a total of 35 staff from adolescent mental health wards (10–12 people in each group), on the nature of compassionate care, aids and barriers. Transcripts were analysed using thematic analysis. A follow-up survey with 36 workers from other UK child and adolescent mental health wards was completed and means and standard deviations of responses were analysed to confirm wider resonance of themes.

Results

Elements of compassionate care fell into six themes relating to individual, team and organisational factors: emotional connection, sense of being valued, attention to the whole person, understanding, good communication, and practical help/resources. Aids and barriers mirrored each other, and showed that what staff think is key to the nature of compassionate care for patients is also what they feel they need to receive to be able to show compassionate care.

Conclusions

This study suggests that staff need the same elements of compassion as those which they seek to provide. A greater emphasis needs to be placed on providing staff with individual, team and organisational level resources which help them to feel compassionately held within the interconnected systems in which they work, in order to be able to continue to provide high level compassionate care. Staff need to be nourished, valued and compassionately cared for in order to be able to care compassionately for the patients they look after.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00994-z.

Palliation of heart failure: value-based supportive care

OBJECTIVES

Heart failure (HF) is a prevalent condition associated with poor quality-of-life and high symptom burden. As patients reach ceilings of survival-extending interventions, their priorities may be more readily addressed through the support of palliative care services; however, the best model of care remains unestablished.We aimed to create and evaluate a cospeciality cross-boundary service model for patients with HF that better provides for their palliative care needs in the latter stages of life, while delivering a more cost-effective patient journey.

METHODS

In 2016, the Heart Failure Supportive Care Service (HFSCS) was established to provide patient-centred holistic support to patients with advanced HF. Patient experience questionnaires were developed and distributed in mid-2018 and end-of-2020. Indexed hospital admission data (in-patient bed days pre-referral/post-referral) were used allowing statistical comparisons by paired t-tests.

RESULTS

From 2016-2020, 236 patients were referred to the HFSCS. Overall, 75/118 questionnaires were returned. Patients felt that the HFSCS delivered compassionate care (84%) that improved symptoms and quality of life (80% and 65%). Introduction of the HFSCS resulted in a reduction in HF-related admissions: actual days 18.3 to 4 days (p<0.001), indexed days 0.05 to 0.032 days (p=0.03). Cost mapping revealed an estimated average saving of at least £10 218.36 per referral and a total estimated cost saving of approximately £2.4 million over 5 years.

CONCLUSION

This service demonstrates that a cospeciality cross-boundary method of care delivery successfully provides the benefits of palliative care to patients with HF in a value-based manner, while meeting the priorities of care that matter to patients most.

Patient views on emergency department screening and interventions related to housing

Objectives Emergency departments (EDs) serve as a health care "safety net" and may be uniquely suited to screening for and addressing patients' unmet social needs. We aimed to better understand patient perspectives on ED-based screening and interventions related to housing instability, as a step toward improving future efforts. Methods We present findings from a qualitative study using in-depth, one-on-one interviews with ED patients who had become homeless in the past 6 months. Qualitative interviewees were asked their thoughts on ED staff asking about and helping to address homelessness and housing issues. Interviews were professionally transcribed verbatim. Multiple coders identified interview text segments focused on ED-based housing screening and intervention, which were then independently analyzed thematically and discussed to reach consensus. Researchers also categorized each participant's overall opinion on ED housing screening and interventions as positive, neutral, or negative. Results Qualitative interviews were conducted with 31 patients. Four themes related to ED-based housing screening and interventions emerged: (1) patients generally welcome ED staff/providers asking about and assisting with their housing situation, with caveats around privacy and respect; (2) ED conversations about housing have potential benefits beyond addressing unmet housing needs; (3) patients may not consider the ED as a site to obtain help with housing; (4) patients' experiences navigating existing housing services can inform best approaches for the ED. Most participants expressed overall positive views of ED staff/providers asking patients about their housing situation. Conclusions Study participants generally felt positively about screening and interventions for housing in the ED. Insights from this study can inform future ED-based housing instability screening and interventions.

People who make frequent emergency department visits based on persistence of frequent use in Ontario and Alberta: a retrospective cohort study

BACKGROUND

The factors that underlie persistent frequent visits to the emergency department are poorly understood. This study aimed to characterize people who visit emergency departments frequently in Ontario and Alberta, by number of years of frequent use.

METHODS

This was a retrospective cohort study aimed at capturing information about patients visiting emergency departments in Ontario and Alberta, Canada, from Apr. 1, 2011, to Mar. 31, 2016. We identified people 18 years or older with frequent emergency department use (top 10% of emergency department use) in fiscal year 2015/16, using the Dynamic Cohort from the Canadian Institute of Health Information. We then organized them into subgroups based on the number of years (1 to 5) in which they met the threshold for frequent use over the study period. We characterized subgroups using linked emergency department, hospitalization and mental health-related hospitalization data.

RESULTS

We identified 252 737 people in Ontario and 63 238 people in Alberta who made frequent visits to the emergency department. In Ontario and Alberta, 44.3% and 44.7%, respectively, met the threshold for frequent use in only 1 year and made 37.9% and 38.5% of visits; 6.8% and 8.2% met the threshold for frequent use over 5 years and made 11.9% and 13.2% of visits. Many characteristics followed gradients based on persistence of frequent use: as years of frequent visits increased (1 to 5 years), people had more comorbidities, homelessness, rural residence, annual emergency department visits, alcohol- and substance use-related presentations, mental health hospitalizations and instances of leaving hospital against medical advice.

INTERPRETATION

Higher levels of comorbidities, mental health issues, substance use and rural residence were seen with increasing years of frequent emergency department use. Interventions upstream and in the emergency department must address unmet needs, including services for substance use and social supports.

Social relationships, homelessness, and substance use among emergency department patients

BACKGROUND

Emergency department (ED) patients commonly experience both substance use and homelessness, and social relationships impact each in varied ways not fully captured by existing quantitative research. This qualitative study examines how social relationships can precipitate or ameliorate homelessness and the connection (if any) between substance use and social relationships among ED patients experiencing homelessness.

METHODS

As part of a broader study to develop ED-based homelessness prevention interventions, we conducted in-depth interviews with 25 ED patients who used alcohol or drugs and had recently become homeless. We asked patients about the relationship between their substance use and homelessness. Interviews were recorded, transcribed, and coded line-by-line by investigators. Final codes formed the basis for thematic analysis through consensus discussions.

RESULTS

Social relationships emerged as focal points for understanding the four major themes related to the intersection of homelessness and substance use: (1) Substance use can create strain in relationships; (2) Help is there until it's not; (3) Social relationships can create challenges contributing to substance use; and (4) Reciprocal relationship of substance use and isolation. Sub-themes were also identified and described.

CONCLUSIONS

The association between substance use and homelessness is multifaceted and social relationships are a complex factor linking the two. Social relationships are often critical for homelessness prevention, but they are impacted by and reciprocally affect substance use. ED-based substance use interventions should consider the high prevalence of homelessness and the impact of social relationships on the interaction between homelessness and substance use.

Emergency Department Utilization by Adolescents Experiencing Homelessness in Massachusetts

BACKGROUND

Adolescents who experience homelessness rely heavily on emergency departments (EDs) for their health care.

OBJECTIVES

This study estimates the relationship between homelessness and ED use and identifies the sociodemographic, clinical, visit-level, and contextual factors associated with multiple ED visits among adolescents experiencing homelessness in Massachusetts.

RESEARCH DESIGN

We used the Healthcare Cost and Utilization Project State Emergency Department Databases on all outpatient ED visits in Massachusetts from 2011 to 2016. We included all adolescents who were 11-21 years old. We estimated the association between homelessness and ED utilization and investigated predictors of multiple ED visits among adolescents who experience homelessness using multivariate logistic and negative binomial regressions.

RESULTS

Our study included 1,196,036 adolescents, of whom about 0.8% experienced homelessness and this subset of adolescents accounted for 2.2% of all ED visits. Compared with those with stable housing, adolescents who were homeless were mostly covered through Medicaid (P<0.001), diagnosed with 1 or more comorbidities (P<0.001), and visited the ED at least once for reasons related to mental health; substance and alcohol use; pregnancy; respiratory distress; urinary and sexually transmitted infections; and skin and subcutaneous tissue diseases (P<0.001). Homeless experience was associated with multiple ED visits (incidence rate ratio=1.18; 95% confidence intervals, 1.16-1.19) and frequent ED use (4 or more ED visits) (adjusted odds ratio=2.21; 95% confidence interval, 2.06-2.37). Factors related to clinical complexity and Medicaid compared with lack of coverage were also significant predictors of elevated ED utilization within the cohort experiencing homelessness.

CONCLUSIONS

Adolescents who experience homelessness exhibit higher ED use compared with those with stable housing, particularly those with aggravated comorbidities and chronic conditions. Health policy interventions to integrate health care, housing, and social services are essential to transition adolescents experiencing homelessness to more appropriate community-based care.

Emergency department interventions for homelessness: a systematic review

BACKGROUND

The social determinants of health are economic and social conditions that contribute to health. Access to housing is a major social determinant of health and homeless patients often rely on emergency departments (EDs) for their healthcare. These patients are frequently discharged back to the street which further perpetuates the cycle of homelessness and negatively affects their health. Previous work has described the financial and systems implications of ED-housed interventions for homeless patients; this review summarizes ED-based interventions that seek to improve the social determinants of health of homeless patients.

METHODS

We conducted a search of multiple databases and gray literature for studies investigating interventions for homelessness that were initiated in the ED. Studies had to use a control group or use a pre/post-intervention design and measure outcomes that demonstrate an effect on health or the social determinants of health.

RESULTS

Thirteen studies were identified that met the inclusion criteria. Two studies were housing first interventions and were effective in providing housing and improving health. Seven studies used variations of case management and were able to address many of the social needs of people who are homeless.

CONCLUSION

This review demonstrated that ED interventions can be effective in improving the social determinants of health of homeless individuals and can be the place to initiate housing interventions. ED providers must advocate for the resources necessary to properly address the social needs of this marginalized population. Equipped with the proper resources, EDs can be one place where the cycle of homelessness is broken.

Top 10 presenting diagnoses of homeless veterans seeking care at emergency departments

BACKGROUND

The health concerns that spur care-seeking in emergency departments (EDs) among homeless populations are not well described. The Veterans Affairs (VA) comprehensive healthcare system does not require health insurance and thus offers a unique window into ED service use by homeless veterans.

OBJECTIVE

This study examined the top 10 diagnostic categories for ED use among homeless and non-homeless veterans classified by age, gender, and race/ethnicity.

DESIGN

An observational study was conducted using national VA administrative data from 2016 to 2019.

PARTICIPANTS

Data on 260,783 homeless veterans and 2,295,704 non-homeless veterans were analyzed.

MAIN MEASURES

Homelessness was defined as a documented diagnostic code or use of any VA homeless program. Presenting diagnoses to the ED were grouped based on Clinical Classifications Software Refined (CCSR) categories endorsed by the Agency for Healthcare Research and Quality (AHRQ).

KEY RESULTS

The most common diagnostic categories for ED use among homeless veterans were, in order, musculoskeletal pain, alcohol-related disorders, suicidal behaviors, low back pain, and non-specified conditions, which together accounted for 22-24% of all ED visits. Among non-homeless veterans, alcohol-related disorders, suicidal behaviors, and depressive disorders did not number in the top 10 diagnostic categories for ED use. Some differences between homeless and non-homeless veterans presenting for ED care, such as age, gender, and race/ethnicity largely mirrored known epidemiological differences between these groups in general. But respiratory infections and symptoms were only in the top 10 for black veterans and depressive disorder was only in the top 10 for Hispanic veterans.

CONCLUSIONS

These data suggest that addressing psychosocial factors and optimizing healthcare for behavioral health and pain conditions among veterans experiencing homelessness has the potential to reduce emergency care-seeking.

The St Thomas' Hospital Emergency Department Homeless Health Initiative: improving the quality, safety and equity of healthcare provided for homeless patients attending the ED

We carried out a quality improvement (QI) project (QIP), aiming to improve the quality, safety and equity of healthcare provided for homeless patients attending the emergency department (ED). We used QI methodology to identify areas for improvement, and introduced and modified interventions over four Plan, Do, Study, Act cycles. We launched a departmental ‘Homeless Health Initiative’ (HHI), the chief intervention being the provision of ‘Homeless Health Boxes’ in the ED, which contained a ‘Safe Discharge Checklist for Homeless Patients’, maps to specialist homeless general practitioner surgeries and homeless day centres, information on other inclusion health services, copies of a local rough sleepers’ magazine and oral hygiene supplies. Voluntary Homeless Link Nurses and a number of informal ‘Homeless Health Champions’ were appointed. The HHI was embedded in departmental awareness through regular presentations to staff and incorporation into the induction programme for new doctors. Staff satisfaction, in terms of how satisfied staff members were with the care they were able to provide for homeless patients in the ED on a 0–10 scale, improved modestly over the course of the QIP from median 6/10 to median 7/10. The number of staff who were severely dissatisfied with the care they were able to provide for homeless patients improved more markedly: first quartile staff satisfaction improved from 3.875/10 to 6.125/10. Staff compliance with the checklist was poor, with full compliance observed in only 15% of cases by the end of the QIP. An HHI is a cheap and worthwhile QI project, with the potential to significantly improve the quality, safety and equity of healthcare provided for homeless patients, while improving staff satisfaction concurrently. Similar initiatives should be considered in any ED which sees a significant number of homeless patients.

The Neuroscience of Happiness and Well-Being: What Brain Findings from Optimism and Compassion Reveal

Increasing behavioral data support the value of developing positive traits and attitudes to promote mental health and human flourishing. A neuroscience approach to understanding the mechanisms of the key constructs of optimism and compassion is relevant toward improving identification and measurement of relevant traits, progress and barriers to cultivating these traits, and identifying which mental health-promoting practices are most effective in promoting growth of optimism and compassion.

Clinical risk for substance-affected patients attending an emergency department in the Northern Territory with police: A quality improvement initiative

OBJECTIVE

Determine clinical risk for patients presenting to Royal Darwin Hospital ED when they cannot be cared for at the police watch-house (WH) or sobering-up-shelter (SUS) because of a medical concern.

METHODS

This is a retrospective cohort study of police arrivals from May to July 2016. Data collection included demographics and presumed cause of intoxication. Outcomes used as markers of risk were departure status, return visit within 24 h and frequency of ED attendance over 3 months. Social determinants of poor health were collected for the June cohort.

RESULTS

There were 247 attendances with police by 170 patients. Most were alcohol affected (monthly rates between 83% and 92%). The 'did not wait/left at own risk' rate was high (41-44% vs 7.7%; P < 0.001) and hospital admission rates low (2-7% vs 29%; P < 0.001). Rates of representation (20% within 24 h), ED attendance (≥73% had a further visit within 3 months), comorbidities (46% with three or more chronic diseases), homelessness (66%) and alcohol dependence (85%) were high. Patients presenting more than five times over 3 months were less likely to wait (odds ratio 2.4, 95% confidence interval 1.1-5.2, P = 0.03).

CONCLUSION

This is a common presentation at Royal Darwin Hospital ED by a patient group with high levels of comorbidity, homelessness and alcohol dependence. Nearly half self-discharged prior to medical assessment. These patients frequently re-attend the same facilities and enter into a cycle of non-intervention. Case management across services is needed to improve the opportunity that these patients receive appropriate medical, social and addiction interventions.

Understanding compassion in family medicine: a qualitative study

BACKGROUND

Patients and physicians have traditionally valued compassion; however, there is concern that physician compassion has declined with the increasing emphasis on science and technology in medicine. Although the literature on compassion is growing, very little is known about how family physicians experience compassion in their work.

AIM

To explore family physicians' capacity for and experiences of compassion in practice.

DESIGN AND SETTING

This was a qualitative study designed using a phenomenological approach in rural and urban Ontario, Canada.

METHOD

In-depth interviews were audiotaped and transcribed verbatim, followed by independent and team coding. An iterative and interpretive analysis was conducted using immersion and crystallisation techniques. Purposive sampling recruited 22 participants (nine males and 13 females aged 26-64 years) that included family medicine residents from Western University (n = 6), and family physicians practising <5 years (n = 7) or >10 years (n = 9) in Ontario, Canada.

RESULTS

From the data, the authors derived the Compassion Trichotomy as a theoretical model to describe three interrelated areas that determine the evolution or devolution of compassion experienced by family physicians: motivation (core values), capacity (energy), and connection (relationship).

CONCLUSION

The Compassion Trichotomy highlights the importance and interdependence in physician compassion of motivation (personal reflection and values), capacity (awareness and regulation of energy, emotion, and cognition), and connection (sustained patient-physician relationship). This model may assist practising family physicians, educators, and researchers to explore how compassion development might enhance physician effectiveness and satisfaction.

Empathy in general practice-the gap between wishes and reality: comparing the views of patients and physicians

BACKGROUND

Empathy is regarded by patients and general practitioners (GPs) as fundamental in patient-GP communication. Patients do not always experience empathy and GPs encounter circumstances which hamper applying it.

OBJECTIVE

To explore why receiving and offering empathy during the encounter in general practice does not always meet the wishes of both patients and GPs.

METHOD

A qualitative research method, based on focus group interviews with patients and in-depth interviews with GPs, was carried out. Within the research process, iterative data collection and analysis were applied.

RESULTS

Both patients and GPs perceive a gap between what they wish for with regard to empathy, and what they actually encounter in general practice. Patients report on circumstances which hamper receiving empathy and GPs on circumstances offering it. Various obstacles were mentioned: (i) circumstances related to practice organization, (ii) circumstances related to patient-GP communication or connectedness, (iii) differences between the patient's and the GP's expectations, (iv) time pressure and its causes and (v) the GP's individual capability to offer empathy.

CONCLUSION

When patients do not receive empathy from their GP or practice staff, they feel frustrated. This causes a gap between their expectations on the one hand and their actual experiences on the other. GPs generally want to incorporate empathy; the GP's private, professional and psychological well-being appears to be an important contributing factor in practicing empathy in daily practice. But they encounter various obstacles to offer this. It is up to GPs to take responsibility for showing practice members the importance of an appropriate empathical behaviour towards patients.

"Hospital was the Only Option": Experiences of Frequent Emergency Department Users in Mental Health

The experiences of individuals with mental illness and addictions who frequently present to hospital emergency departments (EDs) have rarely been explored. This study reports findings from self-reported, quantitative surveys (n = 166) and in-depth, qualitative interviews (n = 20) with frequent ED users with mental health and/or substance use challenges in a large urban centre. Participants presented to hospital for mental health (35 %), alcohol/drug use (21 %), and physical health (39 %) concerns and described their ED visits as unavoidable and appropriate, despite feeling stigmatized by hospital personnel and being discharged without expected treatment. Supporting this population may require alternative service models and attention to staff training in both acute and community settings.

An Inner City Emergency Medicine Rotation Does Not Improve Attitudes toward the Homeless among Junior Medical Learners

Introduction

Learners in the emergency department (ED) frequently encounter individuals who are homeless. We sought to evaluate the effect of an inner city emergency medicine rotation at the Royal Alexandra Hospital (RAH) on the attitudes of medical students and residents towards this population.

Methods

Data were collected both pre- and post-rotation using an electronic survey. Data collected included demographic information and as well as scores on the Health Professionals’ Attitudes Towards the Homeless Inventory (HPATHI). Pre- and post-survey results were compared using Wilcoxon tests.

Results

Ninety-eight students completed the rotation. A total of 40 (41%) students completed both pre- and post-surveys. Demographic information was available for 66 respondents. Most participants were male (42 {64%}), single (47 {71%}), and 30 years of age or younger (59 {89%}). Most participants were of a Caucasian or East/South Asian background (61 {92%}) and grew up in an urban setting (51 {77%}). Overall, 43 (90%) participants saw at least one person who was homeless during their rotation. There was no significant difference between pre- and post-aggregate scores (z = -0.78, p = 0.44), or any of its three subscales (Personal Advocacy, Social Advocacy, and Cynicism).

Conclusion

First year residents and medical students are frequently exposed to patients who are homeless during an inner city ED rotation. Attitudes towards these patients did not significantly change following the rotation. Educational objectives should be set to improve attitudes of learners towards those with unstable housing throughout the ED rotation.

Needs and fears of young people presenting at accident and emergency department following an act of self-harm: secondary analysis of qualitative data

BACKGROUND

Presentation at an accident and emergency (A&E) department is a key opportunity to engage with a young person who self-harms. The needs of this vulnerable group and their fears about presenting to healthcare services, including A&E, are poorly understood.

AIMS

To examine young people's perceptions of A&E treatment following self-harm and their views on what constitutes a positive clinical encounter.

METHOD

Secondary analysis of qualitative data from an experimental online discussion forum. Threads selected for secondary analysis represent the views of 31 young people aged 16-25 with experience of self-harm.

RESULTS

Participants reported avoiding A&E whenever possible, based on their own and others' previous poor experiences. When forced to seek emergency care, they did so with feelings of shame and unworthiness. These feelings were reinforced when they received what they perceived as punitive treatment from A&E staff, perpetuating a cycle of shame, avoidance and further self-harm. Positive encounters were those in which they received 'treatment as usual', i.e. non-discriminatory care, delivered with kindness, which had the potential to challenge negative self-evaluation and break the cycle.

CONCLUSIONS

The clinical needs of young people who self-harm continue to demand urgent attention. Further hypothesis testing and trials of different models of care delivery for this vulnerable group are warranted.

Compassion: a scoping review of the healthcare literature

BACKGROUND

Recent concerns about suboptimal patient care and a lack of compassion have prompted policymakers to question the preparedness of clinicians for the challenging environment in which they practice. Compassionate care is expected by patients and is a professional obligation of clinicians; however, little is known about the state of research on clinical compassion. The purpose of this scoping review was to map the literature on compassion in clinical healthcare.

METHODS

Searches of eight electronic databases and the grey literature were conducted to identify empirical studies published over the last 25 years. Eligible studies explored perceptions or interventions of compassionate care in clinical populations, healthcare professionals, and healthcare students. Following the title and abstract review, two reviewers independently screened full-texts articles, and extracted study data. A narrative approach to synthesizing and mapping the literature was used.

RESULTS AND DISCUSSION

Of 36,637 records, 648 studies were retrieved and 44 studies were included in the review. Less than one third of studies included patients. Six themes emerged from studies that explored perceptions of compassionate care: nature of compassion, development of compassion, interpersonal factors related to compassion, action and practical compassion, barriers and enablers of compassion, and outcomes of compassion. Intervention studies included two compassionate care trials with patients and eight educational programs that aimed to improve compassionate care in clinicians and students.

CONCLUSIONS

This review identifies the limited empirical understanding of compassion in healthcare, highlighting the lack of patient and family voices in compassion research. A deeper understanding of the key behaviors and attitudes that lead to improved patient-reported outcomes through compassionate care is necessary.

Using interpersonal affect regulation in simulated healthcare consultations: an experimental investigation of self-control resource depletion

Controlled Interpersonal Affect Regulation –the process of deliberately influencing the internal feeling states of others– occurs in a variety of interpersonal relationships and contexts. An incipient corpus of research shows that interpersonal affect regulation can be characterized as a goal-directed behavior that uses self-control processes which, according to the strength model of self-regulation, consumes a limited resource that is also used by other self-control processes. Using interpersonal affect-improving and affect-worsening regulation strategies can increase agent’s resource depletion but there is reason to think that effects will partially rely on target’s feedback in response to the regulation. Using a healthcare paradigm, an experiment was conducted to test the combined effects of interpersonal affect regulation use and patient feedback on healthcare workers’ resource depletion, measured as self-reported experienced and expected emotional exhaustion, and persistence on a self-regulation task. Medical students (N = 78) were randomly assigned to a 2(interpersonal affect regulation: affect-worsening vs. affect-improving) × 2(patients’ feedback: positive vs. negative) factorial between-subjects design and given instructions to play the role of doctors in interactions with two professional actors trained to act as patients. Analysis of covariance showed that affect-worsening was more depleting than affect-improving for all measures, whereas the recovery effects of positive feedback varied depending on strategy type and measure. The findings confirm the characterization of interpersonal affect regulation as potentially depleting, but suggest that the correspondence between the agent’s strategy and the target’s response needs to be taken into consideration. Use of affect-improving and positive feedback showed positive effects on self-rated performance, indicating that interpersonal affect regulation is relevant for organizational as well as personal outcomes.

Understanding Why Patients Return to the Emergency Department after Mild Traumatic Brain Injury within 72 Hours

INTRODUCTION

Although there are approximately 1.1 million case presentations of mild traumatic brain injury (mTBI) in the emergency department (ED) each year, little data is available to clinicians to identify patients who are at risk for poor outcomes, including 72-hour ED return after discharge. An understanding of patients at risk for ED return visits during the hyperacute phase following head injury would allow ED providers to develop clinical interventions that reduce its occurrence and improve outcomes.

METHODS

This institutional review board-approved consecutive cohort study collected injury and outcome variables on adults with the purpose of identifying positive predictors for 72-hour ED return visits in mTBI patients.

RESULTS

Of 2,787 mTBI patients, 145 (5%) returned unexpectedly to the ED within 72 hours of hospital discharge. Positive predictors for ED return visits included being male (p=0.0298), being black (p=0.0456), having a lower prehospital Glasgow Coma Score (p=0.0335), suffering the injury due to a motor vehicle collision (p=0.0065), or having a bleed on head computed tomography (CT) (p=0.0334). ED return visits were not significantly associated with age, fracture on head CT, or symptomology following head trauma. Patients with return visits most commonly reported post-concussion syndrome (43.1%), pain (18.7%), and recall for further clinical evaluation (14.6%) as the reason for return. Of the 124 patients who returned to the ED within 72 hours, one out of five were admitted to the hospital for further care, with five requiring intensive care unit stays and four undergoing neurosurgery.

CONCLUSION

Approximately 5% of adult patients who present to the ED for mTBI will return within 72 hours of discharge for further care. Clinicians should identify at-risk individuals during their initial visits and attempt to provide anticipatory guidance when possible.

Difficult behaviors in the emergency department: a cohort study of housed, homeless and alcohol dependent individuals

Background

This study contrasted annual rates of difficult behaviours in emergency departments among cohorts of individuals who were homeless and low-income housed and examined predictors of these events.

Methods

Interviews in 1999 with men who were chronically homeless with drinking problems (CHDP) (n = 50), men from the general homeless population (GH) (n = 61), and men residing in low-income housing (LIH) (n = 58) were linked to catchment area emergency department records (n = 2817) from 1994 to 1999. Interview and hospital data were linked to measures of difficult behaviours.

Results

Among the CHDP group, annual rates of visits with difficult behaviours were 5.46; this was 13.4 (95% CI 10.3–16.5) and 14.3 (95% CI 11.2–17.3) times higher than the GH and LIH groups. Difficult behaviour incidents included physical violence, verbal abuse, uncooperativeness, drug seeking, difficult histories and security involvement. Difficult behaviours made up 57.54% (95% CI 55.43–59.65%), 24% (95% CI 19–29%), and 20% (95% CI 16–24%) of CHDP, GH and LIH visits. Among GH and LIH groups, 87% to 95% were never involved in verbal abuse or violence. Intoxication increased all difficult behaviours while decreasing drug seeking and leaving without being seen. Verbal abuse and violence were less likely among those housed, with odds ratios of 0.24 (0.08, 0.72) and 0.32 (0.15, 0.69), respectively.

Conclusions

Violence and difficult behaviours are much higher among chronically homeless men with drinking problems than general homeless and low-income housed populations. They are concentrated among subgroups of individuals. Intoxication is the strongest predictor of difficult behaviour incidents.

Research-based knowledge in psychology: what, if anything, is its incremental value to the practitioner?

This essay reflects an ongoing dialogue between a clinician versed in mainstream psychological research and theory, and a social psychologist with experience both as a researcher and contributor to applied undertakings in various domains about the "incremental value" of research-based knowledge-that is, its value beyond that provided by the other sources of knowledge available to the practitioner. These sources include knowledge about the needs and coping strategies of all human beings, as well as knowledge both about the specific life circumstances of those one is seeking to help, and knowledge about language and culture. Examples from the clinical practice of the first author are offered, coupled with in-principle arguments about the underspecified and contingent nature of research-based generalizations. By way of rebuttal, examples of arguably useful findings are provided by the second author-especially findings that serve as correctives to biases in lay psychology (notably unwarranted "dispositionism") and to widespread shortcomings in judgment and decision-making (particularly, Kahneman and Tversky's work on "prospect theory" ). Both authors agree on the value of a "bricoleur" treatment strategy that relies on careful attention to the specifics of the case at hand and avoids one-size-fits-all applications of theory and prior research, and both agree that research-based findings are more useful in predicting behavior and designing intervention strategies that apply to groups and large samples of individuals rather than single actors. A concluding discussion focuses on necessary criteria and strategies for increasing the usefulness of laboratory and field research for the practitioner.

Cost-effective: emergency department care coordination with a regional hospital information system

BACKGROUND

Frequent and unnecessary utilization of the emergency department (ED) is often a sign of serious latent patient issues, and the associated costs are shared by many. Helping these patients get the care they need in the appropriate setting is difficult given their complexity, and their tendency to visit multiple EDs.

STUDY OBJECTIVE

We analyzed the cost-effectiveness of a multidisciplinary ED-care-coordination program with a regional hospital information system capable of sharing patients' individualized care plans with cooperating EDs.

METHODS

ED visits, treatment costs, cost per visit, and net income were assessed pre- and postenrollment in the program using nonparametric bootstrapping techniques. Individuals were categorized as frequent (3-11 ED visits in the 365 days preceding enrollment) or extreme (≥12 ED visits) users. Regression to the mean was tested using an adjusted measure of change.

RESULTS

Both frequent and extreme users experienced significant decreases in ED visits (5 and 15, respectively; 95% confidence intervals [CI] 2-5 and 13-17, respectively) and direct-treatment costs ($1285; 95% CI $492-$2364 and $6091; 95% CI $4298-$8998, respectively), leading to significant hospital cost savings and increased net income ($431; 95% CI $112-$878 and $1925; 95% CI $1093-$3159, respectively). The results further indicate that fewer resources were utilized per visit. Regression to the mean did not seem to be an issue.

CONCLUSIONS

When examined as a whole, research on the program suggests that expanding it would be an efficient allocation of hospital, and possibly societal, resources.

New to care: demands on a health system when homeless veterans are enrolled in a medical home model

OBJECTIVES

We compared service use among homeless and nonhomeless veterans newly enrolled in a medical home model and identified patterns of use among homeless veterans associated with reductions in emergency department (ED) use.

METHODS

We used case-control matching with a nested cohort analysis to measure 6-month health services use, new diagnoses, and care use patterns in veterans at the Providence, Rhode Island, Veterans Affairs Medical Center from 2008 to 2011.

RESULTS

We followed 127 homeless and 106 nonhomeless veterans. Both groups had similar rates of chronic medical and mental health diagnoses; 25.4% of the homeless and 18.1% of the nonhomeless group reported active substance abuse. Homeless veterans used significantly more primary, mental health, substance abuse, and ED care during the first 6 months. Homeless veterans who accessed primary care at higher rates (relative risk ratio [RRR] = 1.46; 95% confidence interval [CI] = 1.11, 1.92) or who used specialty and primary care (RRR = 10.95; 95% CI = 1.58, 75.78) had reduced ED usage. Homeless veterans in transitional housing or doubled-up at baseline (RRR = 3.41; 95% CI = 1.24, 9.42) had similar reductions in ED usage.

CONCLUSIONS

Homeless adults had substantial health needs when presenting for care. High-intensity primary care and access to specialty care services could reduce ED use.

When health insurance is not a factor: national comparison of homeless and nonhomeless US veterans who use Veterans Affairs Emergency Departments

OBJECTIVES

We examined the proportion of homeless veterans among users of Veterans Affairs (VA) emergency departments (EDs) and compared sociodemographic and clinical characteristics of homeless and nonhomeless VA emergency department users nationally.

METHODS

We used national VA administrative data from fiscal year 2010 for a cross-sectional study comparing homeless (n = 64,091) and nonhomeless (n = 866,621) ED users on sociodemographics, medical and psychiatric diagnoses, and other clinical characteristics.

RESULTS

Homeless veterans had 4 times the odds of using EDs than nonhomeless veterans. Multivariate analyses found few differences between homeless and nonhomeless ED users on the medical conditions examined, but homeless ED users were more likely to have been diagnosed with a drug use disorder (odds ratio [OR] = 4.12; 95% confidence interval [CI] = 3.97, 4.27), alcohol use disorder (OR = 3.67; 95% CI = 3.55, 3.79), or schizophrenia (OR = 3.44; 95% CI = 3.25, 3.64) in the past year.

CONCLUSIONS

In a national integrated health care system with no specific requirements for health insurance, the major differences found between homeless and nonhomeless ED users were high rates of psychiatric and substance abuse diagnoses. EDs may be an important location for specialized homeless outreach (or "in" reach) services to address mental health and addictive disorders.

When patients are impatient: the communication strategies utilized by emergency department employees to manage patients frustrated by wait times

Studies have documented the frustrations patients experience during long wait times in emergency departments (EDs), but considerably less research has sought to understand ED staff responses to these frustrations. In-depth interviews were conducted with 18 ED social workers, patient navigators, and medical staff members at a large urban hospital regarding their experiences and interpersonal strategies for dealing with frustrated patients. Staff indicated that patients often attribute delays to neglect and do not understand why their health problem is not prioritized. They voiced several strategies for addressing wait time frustrations, including expressing empathy for patients, making patients feel occupied and wait times seem more productive, and educating patients about when health issues should be treated through primary care. All staff members recognized the need for engaging in empathic communication with frustrated patients, but social workers and patient navigators were able to dedicate more time to these types of interactions.

The role of patient attachment and working alliance on patient adherence, satisfaction, and health-related quality of life in lupus treatment

OBJECTIVE

Researchers tested the hypothesis that patients' working alliance with their physicians, and patients' attachment styles would predict patients' adherence, satisfaction, and health-related quality of life.

METHODS

One hundred ninety-three patients diagnosed with lupus participated in an online survey. They completed measures of the Physician-Patient Alliance Inventory, Experiences in Close Relationships Scale, SF-36, General Adherence Inventory, and the Medical Patient Satisfaction Questionnaire.

RESULTS

Working alliance was significantly and positively associated with all three outcome variables of adherence, satisfaction, and quality of life. Attachment avoidance was significantly and negatively related to adherence, and attachment anxiety was significantly and negatively related to health-related quality of life.

CONCLUSIONS

A working alliance between physician and patient, characterized by agreement communication on goals and tasks of treatment, along with trust and patient liking of his/her doctor, predicts patient adherence, satisfaction, and quality of life. Psychological dimensions of attachment also predict patient adherence and quality of life.

PRACTICE IMPLICATIONS

Doctors and other health service providers ought to actively set goals and tasks of treatment, and foster patient trust and liking. A strong relationship with patients can increase treatment efficacy and effectiveness and improve outcomes for individuals with debilitating chronic illnesses such as lupus.

Promoting patient care: work engagement as a mediator between ward service climate and patient-centred care

AIMS

  To test a model that suggests the ward's climate of service facilitates nurses' patient-centred care behaviours through its effect on nurses' work engagement.

BACKGROUND

  Organizational efforts to promote patient-centred care focused on interventions aimed to improve nurses' communication skills, or to improve patient's participation in the decision-making process. These interventions have been only partially successful, as they do not take the ward context into account; so caring professionals who attend workshops can rarely apply their newly acquired skills due to the daily pressures of the ward.

METHOD

  A nested cross-sectional research design (nursing staff within wards) was adopted, with three measures of the care behaviour of nurses. Data were collected in 2009, from 158 nurses working in 40 wards of retirement homes in northern Israel. Nurses' work engagement, ward's climate for service and control variables were measured via validated questionnaires. Patient-centred care behaviours were assessed by structured observations.

RESULTS

  The findings supported our model: service climate proved a link to nurses' work engagement and patient-centred care behaviours. Nurses' work engagement mediated the service-climate patient-centred care behaviours.

CONCLUSION

  The research is pioneering in demonstrating a close relation between ward service climate and patient-centred care. In practice, to improve patient-centred care managers should invest in facilitating ward service climate, highlighting the importance of service to the organization through appropriate rewards, guidance and administrative practices.

Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization and clinical outcomes

OBJECTIVES

We compared a population-tailored approach to primary care for homeless veterans with a usual care approach.

METHODS

We conducted a retrospective prolective cohort study of homeless veterans enrolled in a population-tailored primary care clinic matched to a historical sample in general internal medicine clinics. Overall, 177 patients were enrolled: 79 in the Homeless-Oriented Primary Care Clinic and 98 in general internal medicine primary care.

RESULTS

Homeless-oriented primary care-enrolled patients had greater improvements in hypertension, diabetes, and lipid control, and primary care use was higher during the first 6 months (5.96 visits per person vs 1.63 for general internal medicine) but stabilized to comparable rates during the second 6 months (2.01 vs 1.31, respectively). Emergency department (ED) use was also higher (2.59 vs 1.89 visits), although with 40% lower odds for nonacute ED visits than for the general internal medicine group (95% confidence interval = 0.2, 0.8). Excluding substance abuse and mental health admissions, hospitalizations were reduced among the homeless veterans between the 2 periods (28.6% vs 10.8%; P < .01) compared with the general internal medicine group (48.2% vs 44.4%; P = .6; difference of differences, P < .01).

CONCLUSIONS

Tailoring primary care to homeless veterans can decrease unnecessary ED use and medical admissions and improve chronic disease management.

Can patient-provider interaction increase the effectiveness of medical treatment or even substitute it?--an exploration on why and how to study the specific effect of the provider

OBJECTIVE

Numerous studies demonstrate the impact of high-quality patient-provider interaction (PPI) on health outcomes. However, transformation of these findings into clinical practice is still a crucial problem. One reason might be that health communication research rarely investigated whether PPI can increase the effectiveness of medical treatment and/or even substitute it. Therefore, our objective was to provide empirical and methodological background of why and how to investigate the specific effect of the provider on patients' health outcomes.

METHODS

This is a debate paper based on a narrative (non-systematic) literature review in Medline and PsycINFO without any year limitation.

RESULTS

Neurobiological evidence based on expectation and conditioning theory indicates that PPI is able to increase the effectiveness of medical treatment. Moreover, the use of creative RCT study designs described in this paper enables health communication researchers to investigate whether PPI is able to substitute medical treatment.

CONCLUSION

This paper exemplifies that there exist an evidence-based knowledge from neurobiology as well as creative RCT designs which enable researcher to investigate the specific effects of PPI.

PRACTICE IMPLICATIONS

Research on the specific effects of PPI requires intense reflection on which patient groups or types of illness are reasonable, suitable, and ethically justifiable for interventions.

Usefulness of point-of-care testing in the treatment of diabetes in an underserved population

BACKGROUND

The purpose of this article was to communicate our experience with point-of-care testing (POCT) using Bayer's A1CNow+ device to test glycated hemoglobin (A1C) in the management of diabetes and to share the observations of our quality control efforts.

METHODS

Forty-seven patients' POCT samples were compared with laboratory samples to determine the validity of the POCT sample being drawn. Data collected represent a 10-month time period that were drawn on-site with the following distribution: 36 samples were drawn the same day, 7 samples were drawn 1 day later, 3 samples were drawn within 3 days, and 1 sample was drawn 4 days later. Although all samples were collected on-site, some of the samples were sent to other local branches of nationally recognized laboratories for analysis.

RESULTS

The range of A1C results for the POCT group was 5.6 to >13%. The range of A1C results for the laboratory-drawn group was 5 to 12.6%. Twenty-four patients had laboratory results that read lower than the result obtained in the clinic, with an A1C range of 5 to 12.6%, and two patients had laboratory results that read exactly the same as the result obtained in the clinic when using POCT. These two individuals had A1C results of 9.1 and 12.6%. Analysis of data collected determined an r value of 0.918 demonstrating agreement between the POCT samples and the laboratory samples.

CONCLUSIONS

POCT with the A1CNow+ is an effective, economical tool for use in a pharmacist-based diabetes clinic that serves a high-risk underserved population. POCT allows the pharmacist the ability to use on-site results to inform patients of their progress, modify their therapy immediately with an immediate face-to-face opportunity to assure understanding, and provide a self-management goal.

Expanding clinical empathy: an activist perspective

BACKGROUND

Discussions of empathy in health care offer important ways of enabling communication and interpersonal connection that are therapeutic for the patient and satisfying for the physician. While the best of these discussions offer valuable insights into the patient-physician relationship, many of them lack an action component for alleviating the patient's suffering and emphasize the physician's experience of empathy rather than the patient's experience of illness.

METHODS

By examining educational methods, such as reflective writing exercises and the study of literary texts, and by analyzing theoretical approaches to empathy and suggestions for clinical practice, this article considers how to mindfully keep the focus on what the patient is going through.

CONCLUSION

Clinical empathy can be improved by strategies that address (1) the patient's authority in providing first-person accounts of illness and disability, (2) expanding the concept of empathy to include an action component geared toward relieving patients' suffering, and (3) the potential value of extending empathy to include the social context of illness.

Food, shelter and safety needs motivating homeless persons' visits to an urban emergency department

STUDY OBJECTIVES

We determine whether homeless persons present to the emergency department (ED) for food, shelter, and safety and whether the availability of alternative sites for provision of these needs might decrease their ED presentations.

METHODS

In July to August 2006 and February to March 2007, adult homeless and control (not homeless) patients, who self-presented (nonambulance) to an urban county ED, were interviewed with a structured instrument.

RESULTS

One hundred ninety-one homeless and 63 control subjects were enrolled. Homeless persons spent a mean (standard deviation [SD]) of 3.5 (3.0) nights/week sleeping without shelter and ate a mean (SD) of 2.1 (1.1) meals per day; 51% stated they had been assaulted on the street. On an analog scale, in which 0=no problem and 10=worst possible problem in their daily lives, the mean (SD) homeless subject responses for hunger, lack of shelter, and safety were 4.8 (3.7), 6.1 (4.2), and 5.1 (4.0), respectively. More homeless (29% [55/189]) than not homeless (10% [6/63]) persons replied that hunger, safety concerns, and lack of shelter were reasons they came to the ED (Delta=20%; 95% confidence interval 10% to 29%). If offered a place that would provide food, shelter, and safety at all times, 24% of homeless subjects stated they would not have come to the ED.

CONCLUSION

Homeless persons commonly come to the ED for food, shelter, and safety. Provision of these subsistence needs at all times at another site may decrease their ED presentations.

Emotional disclosure through patient narrative may improve pain and well-being: results of a randomized controlled trial in patients with cancer pain

Narrative medicine is based upon physicians' awareness of patients' narration of their suffering, their hopes, and how illness has affected them. It offers a model for improving health outcomes. To determine whether incorporating a narrative approach in patients with cancer decreases pain intensity and improves their global sense of well-being, we performed a randomized, single-blind controlled trial in adult patients with cancer and average pain intensity levels of at least 5/10. Two hundred thirty-four patients were randomized into three groups: (1) narrative (n=79), in which patients wrote a story about how cancer affected their lives for at least 20 minutes once a week for three weeks; (2) questionnaire (n=77), in which patients filled out the McGill Pain Questionnaire; and (3) control (n=78), in which patients came weekly to medical visits during which they received usual customary care. Patients rated their pain on a 0-10 scale and their well-being on a seven-point Likert scale weekly for eight weeks. Two raters independently evaluated the emotional content of the narratives. Pain intensity and sense of well-being were similar in all groups before and after treatment. Subgroup analyses showed that patients whose narratives had high emotional disclosure had significantly less pain and reported higher well-being scores than patients whose narratives were less emotional. Further study is needed to demonstrate whether the implementation of narrative medicine is associated with health benefits in this and other contexts.

Costly patients with unexplained medical symptoms: a high-risk population

OBJECTIVES

To identify a group of costly patients with unexplained medical symptoms (UMS), and address their needs.

METHODS

Prospective controlled trial; 42 patients with annual costs of care of $6500 or more were randomized into an intervention and a usual care group. A primary care team with expertise in the biopsychosocial (BPS) approach implemented the intervention.

RESULTS

In the intervention group, the annual number of visits to consultants declined from 31.8 to 12.6 (p<.0001) and 14.6 (p=.72) after 1 and 2 years, respectively; visits to hospital emergency wards declined from 33.5 to 4.1 (p<.0001) and 3.5 (p=.18); and in-hospital days declined from 112.7 to 19 (p<.0001) and 6.5 (p=.25). Those parameters remained unchanged in the control group. Five years follow-up demonstrated a reduction in mortality rates between the two groups: 6/21 versus 17/21 (p<0.001).

CONCLUSIONS

When compared to usual care, a BPS intervention was followed by a decline in patients' visits to medical settings and health-care expenditures, along with significant decline in mortality rate.

PRACTICE IMPLICATION

Costly UMS patients should be identified every year and treated using a BPS approach.

[The "doctor" effect in primary care]

AIM

To characterize the factors associated with the 'doctor' effect in primary care, as reported in randomized controlled trials (RCTs).

METHOD

A systematic search of Medline (1964-2004) sought to identify all original reports of RCTs, as well as those reported in reviews and metaanalyses. We used the following key words: RCT, doctor-patient relationship, doctor-patient communication, knowledge, skill, attitude, non-pharmacologic effectiveness, primary care.

RESULTS

Ten RCTs and one metaanalysis provided evidence that a combination of emotional and cognitive care has a consistently positive effect on health outcomes. This effect relies on specific attitudes and skills: empathy, reassurance, explanation, counseling, influencing patients' 'health beliefs and expectations, promoting change in behavior, thoughts or emotions. These can be integrated into a specific patient-centered approach to general practice. Medical education must provide training in the relational skills needed for effective treatment.

CONCLUSION

Qualitative and quantitative research, including RCTs, are necessary; they should be designed to deal with the heterogenous situations and specific characteristics of general practice.

RN-to-MSN Students’ Attitudes Toward Women Experiencing Homelessness: A Focus Group Study

When health professionals, including RNs, have negative attitudes toward women experiencing homelessness, they create barriers to services. It is incumbent on nursing faculty to develop curricula that address homelessness and associated stereotypes, as well as to prepare students to provide safe and appropriate care to the homeless population. The aim of this qualitative study was to examine the attitudes of RN-to-MSN students toward mothers living with their children in a transitional shelter. A convenience sample of 10 students enrolled in a community health nursing course at a university in southern California participated in the study. Two focus groups were conducted: one before and one after a 15-week clinical experience. Data analysis revealed that during the clinical experience, students discovered that they, or perhaps an individual like them, could become homeless. Their attitudes and views changed to include a bigger picture of homelessness, described by public health nursing researchers as "moving upstream." This article suggests strategies for integrating clinical experiences with socioeconomically vulnerable individuals into undergraduate nursing curricula.

Does expressive writing reduce health care utilization? A meta-analysis of randomized trials

This meta-analysis examined whether writing about stressful experiences affects health care utilization (HCU) compared with writing on neutral topics or no-writing control groups. Randomized controlled trials of 30 independent samples representing 2,294 participants were located that contained sufficient information to calculate effect sizes. After omitting one study as an outlier, the effects were combined within 3 homogeneous groups: healthy samples (13 studies), samples with preexisting medical conditions (6 studies), and samples prescreened for psychological criteria (10 studies). Combined effect sizes, Hedges's g (95% confidence interval), with random effects estimation were 0.16 (0.02, 0.31), 0.21 (-0.02, 0.43), and 0.06 (-0.12, 0.24), respectively. Writing about stressful experiences reduces HCU in healthy samples but not in samples defined by medical diagnoses or exposure to stress or other psychological factors. The significance of these effects for individuals' health is unknown.

Does Mindfulness Decrease Stress and Foster Empathy Among Nursing Students?

This pilot study of baccalaureate nursing students explored the effects of an 8-week mindfulness-based stress reduction (MBSR) course on stress and empathy. The course was intended to provide students with tools to cope with personal and professional stress and to foster empathy through intrapersonal knowing. A convenience sample of 16 students participated in the course, used guided meditation audiotapes at home, and completed journal assignments. Stress and empathy were measured using paired sample t tests. Participation in the intervention significantly reduced students' anxiety (p > .05). Favorable trends were observed in a number of stress dimensions including attitude, time pressure, and total stress. Two dimensions of empathy--personal distress and fantasy--also demonstrated favorable downward trends. Regular home meditation was correlated with additional benefit. Participants reported using meditation in daily life and experiencing greater well-being and improved coping skills as a result of the program. Findings suggest that being mindful may also decrease tendencies to take on others' negative emotions. Coping with stress and fostering the affective domain are important facets of nursing education that may be facilitated by mindfulness training.

Can a health advocate for homeless families reduce workload for the primary healthcare team? A controlled trial

The objective of the present study was to determine whether provision of health advocacy for homeless patients would reduce the burden of care for a primary healthcare team. The impact of a health advocacy intervention was assessed in a quasi-experimental, three-armed controlled trial. Homeless patients registering at an inner-city health centre were allocated in alternating periods to health advocacy (with or without outreach registration) or 'usual care' over a total intake period of 3 years. The client group were homeless people in hostels or other temporary accommodation in the Liverpool 8 area of the UK. The majority of participants (n = 400) were women (76%) in their twenties (mean age = 26.6 years). Most (63%) were temporarily housed at either one of the women's refuges or Liverpool City Council family hostels, and all were registered with an inner-city health centre. Data on health service utilisation over a 3-month period was collected for all clients recruited to the study and direct health service costs were measured. Homeless adults who were proactively registered by the health advocate on outreach visits to hostels made significantly less use of health centre resources whilst having more contact with the health advocate than patients who registered at the health centre at a time of need. There was no reduction in health centre workload when the offer of health advocacy was made after registration at the health centre. The additional costs of providing health advocacy were offset by a reduction in demand for health-centre-based care. The results demonstrate that health advocacy can alter the pattern of help-seeking by temporarily homeless adults. The intervention was cost-neutral. The short-term health service workload associated with symptomatic homeless patients requiring medication was not reduced, but outreach health advocacy was used successfully to address psycho-social issues and reduce the workload for primary care staff.