Homelessness and housing crises among individuals accessing services within a Canadian emergency department

"I Have Failed Them and Failed My Duties": Experiences of Hospital Social Workers Discharging Patients into Homelessness

Homelessness is a long-standing issue at the forefront of healthcare globally, and discharge of homeless patients from hospital settings can exacerbate gaps and burdens in healthcare systems. In hospitals, social workers often take on the majority of responsibility for facilitating patient discharge transitions out of hospital care. Research in this area to date has explored experiences and outcomes of homeless clients, and the experiences of social workers in these roles are not well known. The current study's objective was to elucidate observations and experiences of hospital social workers who discharge patients into homelessness. A total of 112 social workers responded to an online questionnaire, and responses to open-ended questions were analyzed for thematic content. Four overarching themes emerged: (1) complexity of clients, (2) systemic barriers, (3) resource gaps, and (4) negative impact on social workers. It is clear that significant change is required to address the multitude of challenges that intersect to reinforce health inequities. Results can be used by social workers, health authorities, community providers, researchers, and policymakers in discussions about best practices for homeless clients.

Homeless Patients Associate Clinician Bias With Suboptimal Care for Mental Illness, Addictions, and Chronic Pain

Objective: To determine how accessible health care services are for people who are experiencing homelessness and to understand from their perspectives what impact clinician bias has on the treatment they receive. Methods: Narrative interviews were conducted with 53 homeless/vulnerably housed individuals in Ontario, Canada. Visit history records were subsequently reviewed at 2 local hospitals, for 52 of the interview participants. Results: Of the 53 participants only 28% had a primary care provider in town, an additional 40% had a provider in another town, and 32% had no access to a primary care provider at all. A subset of the individuals were frequent emergency department users, with 15% accounting for 75% of the identified hospital visits, primarily seeking treatment for mental illness, pain, and addictions. When seeking primary care for these 3 issues participants felt medication was overprescribed. Conversely, in emergency care settings participants felt prejudged by clinicians as being drug-seekers. Participants believed they received poor quality care or were denied care for mental illness, chronic pain, and addictions when clinicians were aware of their housing status. Conclusion: Mental illness, chronic pain, and addictions issues were believed by participants to be poorly treated due to clinician bias at the primary, emergency, and acute care levels. Increased access to primary care in the community could better serve this marginalized population and decrease emergency department visits but must be implemented in a way that respects the rights and dignity of this patient population.

A Critical Ethnography of Outreach Nursing for People Experiencing Homelessness

People experiencing homelessness have a high prevalence of substance abuse and mental and physical problems. Although they have very complex health needs, they face many barriers that reduce their access to health care and social services. Several research studies have shown the need to implement adapted nursing interventions to address these crucial access issues. In this article, we present the results of a critical ethnography of outreach nurses who work with homeless people (n = 12). Robert Castel's theoretical model, which focuses on the process of social disaffiliation, provided the conceptual underpinnings for this research. Our qualitative data analysis revealed four categories, namely 1) the professional role and identity of nurses; 2) the social function of outreach nursing; 3) clinical realities and 4) disaffiliation and stigmatization. Our findings highlight the need to raise awareness among health care providers about the ethical, clinical and organizational issues of homelessness, particularly the mechanisms of exclusion and stigmatization in health care settings that affect people experiencing homelessness.

Critical ethnography of outreach nurses- perceptions of the clinical issues associated with social disaffiliation and stigma

AIMS

The aim of this study was to gain a better understanding of how nurses experience their practice with homeless people. More specifically, we wanted to consider the role as it is practised and certain clinical characteristics associated with social disaffiliation and stigma.

BACKGROUND

Previous research has shown the need to implement adapted nursing interventions to address the problems homeless people encounter in obtaining health services. According to the literature, such interventions have positive health outcomes for homeless people, who exhibit complex health needs.

DESIGN

We chose critical ethnography as our research method.

METHOD

Semi-structured interviews were conducted with 12 nurses who work with people experiencing homelessness in Eastern Canada. They were selected using the convenience sampling method. Recruitment was conducted between June-October 2019.

FINDINGS

Four categories emerged from the qualitative analysis of the data: (1) the professional role and identity of nurses; (2) the social function of outreach nursing; (3) clinical realities; and (4) disaffiliation and stigmatization. In this article, we will present the findings associated with the fourth category.

CONCLUSION

Nursing practice with this population is conducted in non-traditional settings such as shelters, community groups, camps, and the street. Nurses must be able to gain acceptance in these environments in order to forge trusting relationships with disaffiliated and stigmatized patients. Our analysis of the data also indicates that nurses who care for homeless people may be subject to stigma by association or "courtesy stigma."

IMPACT

The results of this critical ethnography are useful in that they highlight the clinical interventions and health policies best suited to a highly marginalized clientele that is poorly served by traditional health services.

The Experiences of Migration among Homeless Male and Female Psychiatric Survivors

Globally, individuals with psychiatric disorders experience an increased risk for homelessness and frequent migration. The present qualitative study used intersectionality and thematic analysis to examine how male and female psychiatric survivors experienced the phenomenon of frequent migration in Canada. The study findings underscored aspects of frequent migration, including negative experiences associated with poverty, as well as increased risks for homelessness and mental health, stigma, and discrimination. The present findings call for bespoken services and programs to address male and female psychiatric survivors' specific needs; thereby alleviating pathways to frequent migrations among psychiatric survivors.

Material Needs of Emergency Department Patients: A Systematic Review

BACKGROUND

Interest in social determinants of health (SDOH) has expanded in recent years, driven by a recognition that such factors may influence health outcomes, services use, and health care costs. One subset of SDOH is material needs such as housing and food. We conducted a systematic review of the literature on material needs among emergency department (ED) patients in the United States.

METHODS

We followed PRISMA guidelines for systematic review methodology. With the assistance of a research librarian, four databases were searched for studies examining material needs among ED patients. Two reviewers independently screened titles, abstracts, and full text to identify eligible articles. Information was abstracted systematically from eligible articles.

RESULTS

Forty-three articles were eligible for inclusion. There was heterogeneity in study methods; single-center, cross-sectional studies were most common. Specific material needs examined included homelessness, poverty, housing insecurity, housing quality, food insecurity, unemployment, difficulty paying for health care, and difficulty affording basic expenses. Studies overwhelmingly supported the notion that ED patients have a high prevalence of a number of material needs.

CONCLUSIONS

Despite some limitations in the individual studies examined in this review, the plurality of prior research confirms that the ED serves a vulnerable population with high rates of material needs. Future research is needed to better understand the role these needs play for ED patients and how to best address them.

Increased 30-Day Emergency Department Revisits Among Homeless Patients with Mental Health Conditions

INTRODUCTION

Patients with mental health conditions frequently use emergency medical services. Many suffer from substance use and homelessness. If they use the emergency department (ED) as their primary source of care, potentially preventable frequent ED revisits and hospital readmissions can worsen an already crowded healthcare system. However, the magnitude to which homelessness affects health service utilization among patients with mental health conditions remains unclear in the medical community. This study assessed the impact of homelessness on 30-day ED revisits and hospital readmissions among patients presenting with mental health conditions in an urban, safety-net hospital.

METHODS

We conducted a secondary analysis of administrative data on all adult ED visits in 2012 in an urban safety-net hospital. Patient demographics, mental health status, homelessness, insurance coverage, level of acuity, and ED disposition per ED visit were analyzed using multilevel modeling to control for multiple visits nested within patients. We performed multivariate logistic regressions to evaluate if homelessness moderated the likelihood of mental health patients' 30-day ED revisits and hospital readmissions.

RESULTS

Study included 139,414 adult ED visits from 92,307 unique patients (43.5±15.1 years, 51.3% male, 68.2% Hispanic/Latino). Nearly 8% of patients presented with mental health conditions, while 4.6% were homeless at any time during the study period. Among patients with mental health conditions, being homeless contributed to an additional 28.0% increase in likelihood (4.28 to 5.48 odds) of 30-day ED revisits and 38.2% increase in likelihood (2.04 to 2.82 odds) of hospital readmission, compared to non-homeless, non-mental health (NHNM) patients as the base category. Adjusted predicted probabilities showed that homeless patients presenting with mental health conditions have a 31.1% chance of returning to the ED within 30-day post discharge and a 3.7% chance of hospital readmission, compared to non-homeless patients presenting with mental health conditions (25.2%, 2.6%) and NHNM (7.7%, 1.5%).

CONCLUSION

Homeless patients presenting with mental health conditions were more likely to return to the ED within 30 days and to be readmitted to the hospital. Interventions providing housing might improve their overall care management and have the potential to reduce ED revisits and hospital readmissions.

Emergency Care for Homeless Patients: A French Multicenter Cohort Study

OBJECTIVES

To determine whether homeless patients experience suboptimal care in the emergency department (ED) by the provision of fewer health care resources.

METHODS

We conducted a prospective multicenter cohort study in 30 EDs in France. During 72 hours in March 2015, all homeless patients that visited the participating EDs were included in the study. The primary health care service measure was the order by the physician of a diagnostic investigation or provision of a treatment in the ED. Secondary measures of health care services included ED waiting time, number and type of investigations per patient, treatment in the ED, and discharge disposition.

RESULTS

A total of 254 homeless patients and 254 nonhomeless patients were included. After excluding homeless patients that attended the ED for the sole purpose of housing, we analyzed 214 homeless and 214 nonhomeless. We found no significant difference between the 2 groups in terms of health care resource consumption, and for our secondary endpoints.

CONCLUSIONS

We did not find significant differences in the level of medical care delivered in French EDs to homeless patients compared with matched nonhomeless patients.