Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings

A scoping review examining patient experience and what matters to people experiencing homelessness when seeking healthcare

BACKGROUND

Homelessness is associated with significant health disparities. Conventional health services often fail to address the unique needs and lived experience of homeless individuals and fail to include participatory design when planning health services. This scoping review aimed to examine areas of patient experience that are most frequently reported by people experiencing homelessness when seeking and receiving healthcare, and to identify existing surveys used to measure patient experience for this cohort.

METHODS

A scoping review was undertaken reported according to the PRISMA-ScR 2020 Statement. Databases were searched on 1 December 2022: MEDLINE, EMBASE, APA PsychINFO and CINAHL. Included studies focused on people experiencing homelessness, healthcare services and patient experience, primary research, published in English from 2010. Qualitative papers and findings were extracted and synthesized against a modified framework based on the National Institute for Health and Care Excellence guidelines for care for people experiencing homelessness, the Institute of Medicine Framework and Lachman's multidimensional quality model. People with lived experience of homelessness were employed as part of the research team.

RESULTS

Thirty-two studies were included. Of these, 22 were qualitative, seven quantitative and three mixed methods, from the United States of America (n = 17), United Kingdom (n = 5), Australia (n = 5) and Canada (n = 4). Health services ranged from primary healthcare to outpatient management, acute care, emergency care and hospital based healthcare. In qualitative papers, the domains of 'accessible and timely', 'person-centred', and values of 'dignity and respect' and 'kindness with compassion' were most prevalent. Among the three patient experience surveys identified, 'accessible and timely' and 'person-centred' were the most frequent domains. The least frequently highlighted domains and values were 'equitable' and 'holistic'. No questions addressed the 'safety' domain.

CONCLUSIONS

The Primary Care Quality-Homeless questionnaire best reflected the priorities for healthcare provision that were highlighted in the qualitative studies of people experiencing homelessness. The most frequently cited domains and values that people experiencing homelessness expressed as important when seeking healthcare were reflected in each of the three survey tools to varying degrees. Findings suggest that the principles of 'Kindness and compassion' require further emphasis when seeking feedback on healthcare experiences and the domains of 'safety', 'equitable', and 'efficiency' are not adequately represented in existing patient experience surveys.

Homelessness And Health: Factors, Evidence, Innovations That Work, And Policy Recommendations

On a single night in 2023, more than 653,000 people experienced homelessness in the United States. In this overview, we highlight structural and individual risk factors that can lead to homelessness, explore evidence on the relationship between homelessness and health, discuss programmatic and policy innovations, and provide policy recommendations. Health system efforts to address homelessness and improve the health of homeless populations have included interventions such as screening for social needs and medical respite programs. Initiatives using the Housing First approach to permanent supportive housing have a strong track record of success. Health care financing innovations using Medicaid Section 1115 waivers offer promising new approaches to improving health and housing for people experiencing homelessness. To substantially reduce homelessness and its many adverse health impacts, changes are needed to increase the supply of affordable housing for households with very low incomes. Health care providers and systems should leverage their political power to advocate for policies that scale durable, evidence-based solutions to reduce homelessness, including increased funding to expand housing choice vouchers and greater investment in the creation and preservation of affordable housing.

Staying safe, feeling welcome, being seen: How spatio-temporal configurations affect relations of care at an inclusive health and wellness centre

BACKGROUND

People experiencing homelessness also experience poorer health and frequently attend acute care settings when primary health care would be better equipped to meet their needs. Existing scholarship identifies a complex mix of individual and structural-level factors affecting primary health care engagement driving this pattern of health services utilisation. We build on this existing knowledge, by bringing the spatio-temporal configurations of primary health care into focus. Specifically, we interrogate how space and time inflect situated practices and relations of care.

METHODS

This study took an ethnographic approach and was conducted 2021-2022 at an inclusive health and wellness centre ("the Centre") in Southeast Queensland, Australia. The data consists of 46 interviews with 48 people with lived experience of homelessness, including participants who use the services offered at the Centre (n = 26) and participants who do not (n = 19). We also interviewed 20 clinical and non-clinical service providers affiliated with the Centre and observed how service delivery took place. Interviews and observations were complemented by visual data, including participant-produced photography. All data were analysed employing a narrative framework.

RESULTS

We present three interrelated themes demonstrating how space and time affect care, that is 'staying safe', 'feeling welcome' and 'being seen'. 'Staying safe' captures the perceptions and practices around safety, which sit in tension with making service users feel welcome. 'Feeling welcome' attends to the sense of being invited to use services free of judgment. 'Being seen' depicts capacities to see a health care provider as well as being understood in one's lived experience.

CONCLUSION

Spatio-temporal configurations, such as attendance policies, consultation modalities and time allocated to care encounters afford differential opportunities to nurture reciprocal relations. We conclude that flexible service configurations can leverage a relational model of care.

PATIENT OR PUBLIC CONTRIBUTION

Service providers were consulted during the design stage of the project and had opportunities to inform data collection instruments. Two service providers contributed to the manuscript as co-authors. People with lived experience of homelessness who use the services at the inclusive health centre contributed as research participants and provided input into the dissemination of findings. The photography they produced has been featured in an in-person exhibition, to which some have contributed as consultants or curators. It is hoped that their insights into experiences of welcomeness, safety and being seen will inform flexible and relational primary health care design, delivery, and evaluation to better cater for people experiencing housing instability and poverty.

Ambulatory Intensive Care for Medically Complex Patients at a Health Care Clinic for Individuals Experiencing Homelessness: The SUMMIT Randomized Clinical Trial

Importance

Intensive primary care interventions have been promoted to reduce hospitalization rates and improve health outcomes for medically complex patients, but evidence of their efficacy is limited.

Objective

To assess the efficacy of a multidisciplinary ambulatory intensive care unit (A-ICU) intervention on health care utilization and patient-reported outcomes.

Design, Setting, and Participants

The Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT) randomized clinical trial used a wait-list control design and was conducted at a health care clinic for patients experiencing homelessness in Portland, Oregon. The first patient was enrolled in August 2016, and the last patient was enrolled in November 2019. Included patients had 1 or more hospitalizations in the prior 6 months and 2 or more chronic medical conditions, substance use disorder, or mental illness. Data analysis was performed between March and May 2021.

Intervention

The A-ICU included a team manager, a pharmacist, a nurse, care coordinators, social workers, and physicians. Activities included comprehensive 90-minute intake, transitional care coordination, and flexible appointments, with reduced panel size. Enhanced usual care (EUC), consisting of team-based primary care with access to community health workers and mental health, addiction treatment, and pharmacy services, served as the comparator. Participants who received EUC joined the A-ICU intervention after 6 months.

Main Outcomes and Measures

The main outcome was the difference in rates of hospitalization (primary outcome), emergency department (ED) visits, and primary care physician (PCP) visits per person over 6 months (vs the prior 6 months). Patient-reported outcomes included changes in patient activation, experience, health-related quality of life, and self-rated health at 6 months (vs baseline). We performed an intention-to-treat analysis using a linear mixed-effects model with a random intercept for each patient to examine the association between study group and outcomes.

Results

This study randomized 159 participants (mean [SD] age, 54.9 [9.8] years) to the A-ICU SUMMIT intervention (n = 80) or to EUC (n = 79). The majority of participants were men (102 [65.8%]) and most were White (121 [76.1%]). A total of 64 participants (41.0%) reported having unstable housing at baseline. Six-month hospitalizations decreased in both the A-ICU and EUC groups, with no difference between them (mean [SE], -0.6 [0.5] vs -0.9 [0.5]; difference, 0.3 [95% CI, -1.0 to 1.5]). Emergency department use did not differ between groups (mean [SE], -2.0 [1.0] vs 0.9 [1.0] visits per person; difference, -1.1 [95% CI, -3.7 to 1.6]). Primary care physician visits increased in the A-ICU group (mean [SE], 4.2 [1.6] vs -2.0 [1.6] per person; difference, 6.1 [95% CI, 1.8 to 10.4]). Patients in the A-ICU group reported improved social functioning (mean [SE], 4.7 [2.0] vs -1.1 [2.0]; difference, 5.8 [95% CI, 0.3 to 11.2]) and self-rated health (mean [SE], 0.7 [0.3] vs -0.2 [0.3]; difference, 1.0 [95% CI, 0.1 to 1.8]) compared with patients in the EUC group. No differences in patient activation or experience were observed.

Conclusions and Relevance

The A-ICU intervention did not change hospital or ED utilization at 6 months but increased PCP visits and improved patient well-being. Longer-term studies are needed to evaluate whether these observed improvements lead to eventual changes in acute care utilization.

Trial Registration

ClinicalTrials.gov Identifier: NCT03224858.

Evaluation of Eye Gaze Dynamics During Physician-Patient-Computer Interaction in Federally Qualified Health Centers: Systematic Analysis

BACKGROUND

Understanding the communication between physicians and patients can identify areas where they can improve and build stronger relationships. This led to better patient outcomes including increased engagement, enhanced adherence to treatment plan, and a boost in trust.

OBJECTIVE

This study investigates eye gaze directions of physicians, patients, and computers in naturalistic medical encounters at Federally Qualified Health Centers to understand communication patterns given different patients' diverse backgrounds. The aim is to support the building and designing of health information technologies, which will facilitate the improvement of patient outcomes.

METHODS

Data were obtained from 77 videotaped medical encounters in 2014 from 3 Federally Qualified Health Centers in Chicago, Illinois, that included 11 physicians and 77 patients. Self-reported surveys were collected from physicians and patients. A systematic analysis approach was used to thoroughly examine and analyze the data. The dynamics of eye gazes during interactions between physicians, patients, and computers were evaluated using the lag sequential analysis method. The objective of the study was to identify significant behavior patterns from the 6 predefined patterns initiated by both physicians and patients. The association between eye gaze patterns was examined using the Pearson chi-square test and the Yule Q test.

RESULTS

The results of the lag sequential method showed that 3 out of 6 doctor-initiated gaze patterns were followed by patient-response gaze patterns. Moreover, 4 out of 6 patient-initiated patterns were significantly followed by doctor-response gaze patterns. Unlike the findings in previous studies, doctor-initiated eye gaze behavior patterns were not leading patients' eye gaze. Moreover, patient-initiated eye gaze behavior patterns were significant in certain circumstances, particularly when interacting with physicians.

CONCLUSIONS

This study examined several physician-patient-computer interaction patterns in naturalistic settings using lag sequential analysis. The data indicated a significant influence of the patients' gazes on physicians. The findings revealed that physicians demonstrated a higher tendency to engage with patients by reciprocating the patient's eye gaze when the patient looked at them. However, the reverse pattern was not observed, suggesting a lack of reciprocal gaze from patients toward physicians and a tendency to not direct their gaze toward a specific object. Furthermore, patients exhibited a preference for the computer when physicians directed their eye gaze toward it.

Quality of Depression Care for Veterans Affairs Primary Care Patients with Experiences of Homelessness

BACKGROUND

Persons who experience homelessness (PEH) have high rates of depression and incur challenges accessing high-quality health care. Some Veterans Affairs (VA) facilities offer homeless-tailored primary care clinics, although such tailoring is not required, within or outside VA. Whether services tailoring enhances care for depression is unstudied.

OBJECTIVE

To determine whether PEH in homeless-tailored primary care settings receive higher quality of depression care, compared to PEH in usual VA primary care.

DESIGN

Retrospective cohort study of depression treatment among a regional cohort of VA primary care patients (2016-2019).

PARTICIPANTS

PEH diagnosed or treated for a depressive disorder.

MAIN MEASURES

The quality measures were timely follow-up care (3 + completed visits with a primary care or mental health specialist provider, or 3 + psychotherapy sessions) within 84 days of a positive PHQ-2 screen result, timely follow-up care within 180 days, and minimally appropriate treatment (4 + mental health visits, 3 + psychotherapy visits, 60 + days antidepressant) within 365 days. We applied multivariable mixed-effect logistic regressions to model differences in care quality for PEH in homeless-tailored versus usual primary care settings.

KEY RESULTS

Thirteen percent of PEH with depressive disorders received homeless-tailored primary care (n = 374), compared to usual VA primary care (n = 2469). Tailored clinics served more PEH who were Black, who were non-married, and who had low income, serious mental illness, and substance use disorders. Among all PEH, 48% received timely follow-up care within 84 days of depression screening, 67% within 180 days, and 83% received minimally appropriate treatment. Quality metric attainment was higher for PEH in homeless-tailored clinics, compared to PEH in usual VA primary care: follow-up within 84 days (63% versus 46%; adjusted odds ratio [AOR] = 1.61, p = .001), follow-up within 180 days (78% versus 66%; AOR = 1.51, p = .003), and minimally appropriate treatment (89% versus 82%; AOR = 1.58, p = .004).

CONCLUSIONS

Homeless-tailored primary care approaches may improve depression care for PEH.

Primary Care for Veterans Experiencing Homelessness: a Narrative Review of the Homeless Patient Aligned Care Team (HPACT) Model

In 2011, the U.S. Department of Veterans Health (VA) implemented a homeless-tailored primary care medical home model called the Homeless Patient Aligned Care Teams (HPACTs). The impact of HPACTs on health and healthcare outcomes of veterans experiencing homelessness has not been adequately synthesized. This narrative review summarized peer-reviewed studies published in databases Ovid MEDLINE, Ovid EMBASE, and APA PsycInfo from 1946 to February 2022. Only original research studies that reported outcomes of the HPACT model were included in the review. Of 575 studies that were initially identified and screened, 26 studies met inclusion criteria and were included in this review. Included studies were categorized into studies that described the following: (1) early HPACT pilot implementation; (2) HPACT's association with service quality and utilization; and (3) specialized HPACT programs. Together, studies in this review suggest HPACT is associated with reductions in emergency department utilization and improvements in primary care utilization, engagement, and positive patient experiences; however, the methodological rigor of the included studies was low, and thus, these findings should only be considered preliminary. There is a need for randomized controlled trials assessing the impact of the PACT model on key outcomes of interest, as well as to determine whether the model is a viable way to manage healthcare for persons experiencing homelessness outside of the VA system.

What do Veterans with homeless experience want us to know that we are not asking? A qualitative content analysis of comments from a national survey of healthcare experience

Surveys of people who experience homelessness can portray their life and healthcare experiences with a level of statistical precision; however, few have explored how the very same surveys can deliver qualitative insights as well. In responding to surveys, people experiencing homelessness can use the margins to highlight health and social concerns that investigators failed to anticipate that standard question batteries miss. This study describes the unprompted comments of a large national survey of Veterans with homeless experiences. The Primary Care Quality-Homeless Services Tailoring (PCQ-HOST) survey presented 85 close-ended items to solicit social and psychological experiences, health conditions, and patient ratings of primary care. Amongst 5377 Veterans responding to the paper survey, 657 (12%) offered 1933 unprompted comments across nearly all domains queried. Using a team-based content analysis approach, we coded and organised survey comments by survey domain, and identified emergent themes. Respondents used comments for many purposes. They noted when questions called for more nuanced responses than those allowed, especially 'sometimes' or 'not applicable' on sensitive questions, such as substance use, where recovery status was not queried. On such matters, the options of 'no' and 'yes' failed to capture important contextual and historical information that mattered to respondents, such as being in recovery. Respondents also elaborated on negative and positive care experiences, often naming specific clinics or clinicians. This study highlights the degree to which members of vulnerable populations, who participate in survey research, want researchers to know the reasons behind their responses and topics (like chronic pain and substance use disorders) that could benefit from open-ended response options. Understanding patient perspectives can help improve care. Quantitative data from surveys can provide statistical precision but may miss key patient perspectives. The content that patients write into survey margins can highlight shortfalls of a survey and point towards future areas of inquiry. Veterans with homeless experience want to provide additional detail about their lives and care experiences in ways that transcend the boundaries of close-ended survey questions. Questions on substance use proved especially likely to draw comments that went beyond the permitted response options, often to declare that the respondent was in recovery. Respondents frequently clarified aspects of their care experiences related to pain, pain care, transportation and experiences of homelessness.

Insights for Conducting Large-Scale Surveys with Veterans Who Have Experienced Homelessness

Surveys of underserved patient populations are needed to guide quality improvement efforts but are challenging to implement. The goal of this study was to describe recruitment and response to a national survey of Veterans with homeless experience (VHE). We randomly selected 14,340 potential participants from 26 U.S. Department of Veterans Affairs (VA) facilities. A survey contract organization verified/updated addresses from VA administrative data with a commercial address database, then attempted to recruit VHE through 4 mailings, telephone follow-up, and a $10 incentive. We used mixed-effects logistic regressions to test for differences in survey response by patient characteristics. The response rate was 40.2% (n=5,766). Addresses from VA data elicited a higher response rate than addresses from commercial sources (46.9% vs 31.2%, p<.001). Residential addresses elicited a higher response rate than business addresses (43.8% vs 26.2%, p<.001). Compared to non-respondents, respondents were older, less likely to have mental health, drug, or alcohol conditions, and had fewer VA housing and emergency service visits. Collectively, our results indicated a national mailed survey approach is feasible and successful for reaching VA patients who have recently experienced homelessness. These findings offer insight into how health systems can obtain perspectives of socially disadvantaged groups.

Health services and the Project RoomKey COVID-19 initiative for the unhoused: A university and community partnership

A hotel-based clinic to serve Project RoomKey residents is a model for meeting the health care needs of an unhoused population. The purpose of this paper is to describe the health services provided by students and licensed clinicians at a hotel that was designed to allow unhoused community residents to shelter in place during the early stages of the Covid pandemic (May 1–June 30, 2020). Documents developed for the project may be useful to others who are setting up similar services for unhoused residents in their own communities.