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Hudani A, Labonté R, Yaya S. Where's the Disconnect? Exploring Pathways to Healthcare Coordinated for Youth Experiencing Homelessness in Toronto, Canada, Using Grounded Theory Methodology. QUALITATIVE HEALTH RESEARCH 2024; 34:298-310. [PMID: 37948631 PMCID: PMC10905976 DOI: 10.1177/10497323231208417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
About 900 youth experiencing homelessness (YEH) reside at an emergency youth shelter (EYS) in Toronto on any given night. Several EYSs offer access to healthcare based on youths' needs, including access to primary care, and mental health and addictions support. However, youth also require healthcare from the broader health system, which is often challenging to navigate and access. Currently, little is known about healthcare coordination efforts between the EYS and health systems for YEH. Using grounded theory methodology, we interviewed 24 stakeholders and concurrently analyzed and compared data to explore pathways to healthcare coordinated for youth who reside at an EYS in Toronto. We also investigated fundamental parts (i.e., norms, resources, regulations, and operations) within the EYS and health systems that influence these pathways to healthcare using thematic analysis. A significant healthcare coordination gap was found between these two systems, typically when youth experience crises, often resulting in a recurring loop of transition and discharge between EYSs and hospitals. Several parts within each system act interdependently in hindering adequate healthcare coordination between the EYS and health systems. Incorporating training for system staff on how to effectively coordinate healthcare and work with homeless populations who have complex health needs, and rethinking information-sharing policies within circles of care are examples of how system parts can be targeted to improve healthcare coordination for YEH. Establishing multidisciplinary healthcare teams specialized to serve the complex needs of YEH may also improve healthcare coordination between systems, and access and quality of healthcare for this population.
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Affiliation(s)
- Alzahra Hudani
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Ronald Labonté
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Sanni Yaya
- School of International Development and Global Studies, University of Ottawa, Ottawa, ON, Canada
- The George Institute for Global Health, Imperial College London, London, UK
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McManus PT. Is the 1948 model of access to free healthcare still appropriate today? J R Soc Med 2023; 116:437-440. [PMID: 38054401 PMCID: PMC10850871 DOI: 10.1177/01410768231216434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Affiliation(s)
- Peter Terence McManus
- Belfast Trust, Northern Ireland Medical and Dental Training Agency, Belfast BT8 7RL, UK
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Tulloch AD, Khan Z, Hewett N, Koehne S, Rao R. Evaluation of a Pathway team for homeless mental health in-patients. BJPsych Bull 2023; 47:255-262. [PMID: 36872081 PMCID: PMC10764855 DOI: 10.1192/bjb.2022.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 09/06/2022] [Accepted: 09/10/2022] [Indexed: 03/07/2023] Open
Abstract
AIMS AND METHOD The Pathway model is an enhanced care coordination model for homeless people in hospital. We aimed to evaluate the first attempt to apply it on psychiatric wards, which started in 2015 in South London. We developed a logic model which expressed how the Pathway approach might work. Two predictions from this model were tested, using propensity scores and regression to estimate the effect of the intervention among people who were eligible for it. RESULTS The Pathway team theorised that their interventions would reduce length of stay, improve housing outcomes and optimise the use of primary care - and, more tentatively, reduce readmission and emergency presentations. We were able to estimate effects on length of stay (-20.3 days; 95% CI -32.5 to -8.1; P = 0.0012) and readmission (a non-significant reduction). CLINICAL IMPLICATIONS The marked reduction in length of stay, explicable in terms of the logic model, constitutes preliminary support for the Pathway model in mental health services.
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Affiliation(s)
- Alex D. Tulloch
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, UK
| | - Zana Khan
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Sophie Koehne
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Ranga Rao
- South London and Maudsley NHS Foundation Trust, London, UK
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Malden S, Doi L, Ng L, Cuthill F. Reducing hospital readmissions amongst people experiencing homelessness: a mixed-methods evaluation of a multi-disciplinary hospital in-reach programme. BMC Public Health 2023; 23:1117. [PMID: 37308856 PMCID: PMC10258765 DOI: 10.1186/s12889-023-16048-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 06/03/2023] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION People experiencing homelessness are at increased risk of experiencing ill-health. They are often readmitted to hospital after discharge, usually for the same or similar reasons for initial hospitalisation. One way of addressing this issue is through hospital in-reach initiatives, which have been established to enhance the treatment and discharge pathways that patients identified as homeless receive after hospital admission. Since 2020, the Hospital In-reach programme (which involves targeted clinical interventions and structured discharge support) has been piloted in two large National Health Service (NHS) hospitals in Edinburgh, United Kingdom (UK). This study describes an evaluation of the programme. METHODS This evaluation used a mixed method, pre-post design. To assess the effect of the programme on hospital readmission rates from baseline (12 months pre-intervention) and follow-up (12 months post-intervention), aggregate data describing the proportions of homeless-affected individuals admitted to hospital during the evaluation period were analysed using Wilcoxon signed rank test, with level of significance set at p = 0.05. Qualitative interviews were conducted with fifteen programme and hospital staff (nurses, general practitioners, homeless link workers) to assess the processes of the programme. RESULTS A total of 768 referrals, including readmissions, were made to the In-reach programme during the study period, of which eighty-eight individuals were followed up as part of the study. In comparison to admissions in the previous 12 months, readmissions were significantly reduced at 12 months follow-up by 68.7% (P = 0.001) for those who received an in-reach intervention of any kind. Qualitative findings showed that the programme was valued by hospital staff and homeless community workers. Housing services and clinical staff attributed improvements in services to their ability to collaborate more effectively in secondary care settings. This ensured treatment regimens were completed and housing was retained during hospital admission, which facilitated earlier discharge planning. CONCLUSIONS A multidisciplinary approach to reducing readmissions in people experiencing homelessness was effective at reducing readmissions over a 12-month period. The programme appears to have enhanced the ability for multiple agencies to work more closely and ensure the appropriate care is provided for those at risk of readmission to hospital among people affected by homelessness.
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Affiliation(s)
- Stephen Malden
- Scottish Collaboration for Public Health Research and Policy, University of Edinburgh, Edinburgh, EH8 9AG, Scotland.
| | - Lawrence Doi
- Scottish Collaboration for Public Health Research and Policy, University of Edinburgh, Edinburgh, EH8 9AG, Scotland
- Nursing Studies, School of Health in Social Science, University of Edinburgh, Edinburgh, Scotland
| | - Lauren Ng
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, Scotland
| | - Fiona Cuthill
- Nursing Studies, School of Health in Social Science, University of Edinburgh, Edinburgh, Scotland
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Grimes T, Marcilly R, Bonnici West L, Cordina M. Medication-Related Outcomes and Health Equity: Evidence for Pharmaceutical Care. PHARMACY 2023; 11:pharmacy11020060. [PMID: 36961038 PMCID: PMC10037618 DOI: 10.3390/pharmacy11020060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/25/2023] Open
Abstract
Marginalised people experience diminished access to pharmaceutical care and worse medication-related outcomes than the general population. Health equity is a global priority. This article explores the key evidence of health inequity and medication use, structures the causes and contributory factors and suggests opportunities that can be taken to advance the pharmaceutical care agenda so as to achieve health equity. The causes of, and contributors to, this inequity are multi-fold, with patient- and person-related factors being the most commonly reported. Limited evidence is available to identify risk factors related to other aspects of a personal medication use system, such as technology, tasks, tools and the internal and the external environments. Multiple opportunities exist to enhance equity in medication-related outcomes through pharmaceutical care research and practice. To optimise the effects and the sustainable implementation of these opportunities, it is important to (1) ensure the meaningful inclusion and engagement of members of marginalised groups, (2) use a person-centred approach and (3) apply a systems-based approach to address all of the necessary components of a system that interact and form a network as work processes that produce system outcomes.
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Affiliation(s)
- Tamasine Grimes
- School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, D02PN40 Dublin, Ireland
| | - Romaric Marcilly
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, F-59000 Lille, France
- Inserm, CIC-IT 1403, F-59000 Lille, France
| | - Lorna Bonnici West
- Applied Research and Innovation Centre, Malta College of Arts, Science and Technology, PLA9032 Paola, Malta
| | - Maria Cordina
- Department of Clinical Pharmacology & Therapeutics, WHO Collaborating Centre for Health Professionals Education and Research, Faculty of Medicine and Surgery, University of Malta, 2080 Msida, Malta
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Currie J, Stafford A, Hutton J, Wood L. Optimising Access to Healthcare for Patients Experiencing Homelessness in Hospital Emergency Departments. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2424. [PMID: 36767794 PMCID: PMC9916150 DOI: 10.3390/ijerph20032424] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 06/18/2023]
Abstract
The ED is often the first and sometimes the only place where people experiencing homelessness seek medical assistance. While access to primary healthcare is a preferable and more cost-effective alternative to ED, for many reasons, people experiencing homelessness are much less likely to have a regular General Practitioner compared to those living in stable accommodation. Drawing on a growing body of emergency care and homelessness literature and practice, we have synthesised four potential interventions to optimise access to care when people experiencing homelessness present to an ED. Although EDs are in no way responsible for resolving the complex health and social issues of their local homeless population, they are a common contact point and therefore present an opportunity to improve access to healthcare.
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Affiliation(s)
- Jane Currie
- School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, QLD 4059, Australia
| | | | - Jennie Hutton
- Emergency Department, St Vincent’s Hospital Melbourne, Melbourne, VIC 3065, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC 3010, Australia
| | - Lisa Wood
- Institute for Health Research, University of Notre Dame, Fremantle, WA 6061, Australia
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Dorney-Smith S. Homelessness during the pandemic: helping the most vulnerable. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:248-250. [PMID: 35220739 DOI: 10.12968/bjon.2022.31.4.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Sam Dorney-Smith, Nursing Fellow, Pathway, and Specialist Advisor, Homeless Health Programme, Queen's Nursing Institute, London (samantha.dorney-smith@nhs.net), runner-up in the Nurse of the Year category of the BJN Awards 2021.
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Affiliation(s)
- Sam Dorney-Smith
- Nursing Fellow, Pathway, and Specialist Advisor, Homeless Health Programme, Queen's Nursing Institute, London
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Cornes M, Aldridge RW, Biswell E, Byng R, Clark M, Foster G, Fuller J, Hayward A, Hewett N, Kilmister A, Manthorpe J, Neale J, Tinelli M, Whiteford M. Improving care transfers for homeless patients after hospital discharge: a realist evaluation. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
In 2013, 70% of people who were homeless on admission to hospital were discharged back to the street without having their care and support needs addressed. In response, the UK government provided funding for 52 new specialist homeless hospital discharge schemes. This study employed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines between September 2015 and 2019 to undertake a realist evaluation to establish what worked, for whom, under what circumstances and why. It was hypothesised that delivering outcomes linked to consistently safe, timely care transfers for homeless patients would depend on hospital discharge schemes implementing a series of high-impact changes (resource mechanisms). These changes encompassed multidisciplinary discharge co-ordination (delivered through clinically led homeless teams) and ‘step-down’ intermediate care. These facilitated time-limited care and support and alternative pathways out of hospital for people who could not go straight home.
Methods
The realist hypothesis was tested empirically and refined through three work packages. Work package 1 generated seven qualitative case studies, comparing sites with different types of specialist homeless hospital discharge schemes (n = 5) and those with no specialist discharge scheme (standard care) (n = 2). Methods of data collection included interviews with 77 practitioners and stakeholders and 70 people who were homeless on admission to hospital. A ‘data linkage’ process (work package 2) and an economic evaluation (work package 3) were also undertaken. The data linkage process resulted in data being collected on > 3882 patients from 17 discharge schemes across England. The study involved people with lived experience of homelessness in all stages.
Results
There was strong evidence to support our realist hypothesis. Specialist homeless hospital discharge schemes employing multidisciplinary discharge co-ordination and ‘step-down’ intermediate care were more effective and cost-effective than standard care. Specialist care was shown to reduce delayed transfers of care. Accident and emergency visits were also 18% lower among homeless patients discharged at a site with a step-down service than at those without. However, there was an impact on the effectiveness of the schemes when they were underfunded or when there was a shortage of permanent supportive housing and longer-term care and support. In these contexts, it remained (tacitly) accepted practice (across both standard and specialist care sites) to discharge homeless patients to the streets, rather than delay their transfer. We found little evidence that discharge schemes fired a change in reasoning with regard to the cultural distance that positions ‘homeless patients’ as somehow less vulnerable than other groups of patients. We refined our hypothesis to reflect that high-impact changes need to be underpinned by robust adult safeguarding.
Strengths and limitations
To our knowledge, this is the largest study of the outcomes of homeless patients discharged from hospital in the UK. Owing to issues with the comparator group, the effectiveness analysis undertaken for the data linkage was limited to comparisons of different types of specialist discharge scheme (rather than specialist vs. standard care).
Future work
There is a need to consider approaches that align with those for value or alliance-based commissioning where the evaluative gaze is shifted from discrete interventions to understanding how the system is working as a whole to deliver outcomes for a defined patient population.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Michelle Cornes
- Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Robert W Aldridge
- Institute of Health Informatics, University College London, London, UK
| | - Elizabeth Biswell
- Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Richard Byng
- Clinical Trials and Health Research, University of Plymouth, Plymouth, UK
| | - Michael Clark
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Graham Foster
- Blizard Institute, Queen Mary University of London, London, UK
| | - James Fuller
- Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Andrew Hayward
- Institute of Health Informatics, University College London, London, UK
| | - Nigel Hewett
- Pathway and the Faculty for Homeless and Inclusion Health, London, UK
| | - Alan Kilmister
- Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Jill Manthorpe
- Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Michela Tinelli
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Martin Whiteford
- Department of Community Nursing and Community Health, Glasgow Caledonian University, Glasgow, UK
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9
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Lane DA. Homelessness: a ‘cause of the causes’ of cardiovascular disease? BRITISH HEART JOURNAL 2020; 106:1456-1457. [DOI: 10.1136/heartjnl-2020-317224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Khan Z, McCrone P, Koehne S. Impact on the use and cost of other services following intervention by an inpatient pathway homelessness team in an acute mental health hospital. J Ment Health 2020; 31:325-331. [PMID: 32336180 DOI: 10.1080/09638237.2020.1755017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Mental illness in people experiencing homelessness is common and a key reason for attendance at emergency departments and admission to hospital.Aims: This paper describes how the KHP Pathway homeless team impacted use and cost of health and wider services. The Pathway model had never been adopted by a mental health hospital, and there had never been an economic analysis to evaluate service use before and after intervention.Method: Service use was measured using an adapted version of the Client Service Receipt Inventory (CSRI) with a simple before and after design at admission, 3 months and 6 months after discharge from hospital.Results: During the first 3-month follow-up, over half the participants saw a GP, with an increase in the proportion seeing a psychiatrist, social worker and a mental health nurse. Attendance at emergency departments was substantially lower than at baseline. The mean total service cost was £818 at base line and £414 at 3 months.Conclusions: The adapted version of the CSRI demonstrates that patients seen by the Pathway Homelessness Team were supported to use community and scheduled health and care services. The service overcomes barriers, frequently experienced by people experiencing homelessness, in accessing support and community healthcare in the UK.
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Affiliation(s)
- Zana Khan
- King's Health Partners Pathway Homeless Team, South London and Maudsley NHS Trust, London, UK
| | - Paul McCrone
- King's Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sophie Koehne
- King's Health Partners Pathway Homeless Team, South London and Maudsley NHS Trust, London, UK
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Field H, Hudson B, Hewett N, Khan Z. Secondary care usage and characteristics of hospital inpatients referred to a UK homeless health team: a retrospective service evaluation. BMC Health Serv Res 2019; 19:857. [PMID: 31752857 PMCID: PMC6868755 DOI: 10.1186/s12913-019-4620-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/03/2019] [Indexed: 11/16/2022] Open
Abstract
Background UK “Pathway” teams offer specialist hospital care coordination for people experiencing homelessness. Emergency healthcare use is high among homeless people, yet “homelessness” is not routinely coded in National Health Service (NHS) data. Pathway team records provide an opportunity to assess patterns in admissions and outcomes for inpatients identified as homeless. Methods Retrospective analysis of patients referred to “Pathway” homelessness teams in seven UK hospitals to explore the patterns of hospital admission, morbidity, secondary healthcare utilisation and housing status. Each patient was individually identified as experiencing homelessness. Within a six-month period, demographic data, reason for admission, morbidity, mortality and secondary care hospital usage 120-days before and 120-days after the index admission was collected. Results A total of 1009 patients were referred, resulting in 1135 admissions. Most admissions had an acute physical health need (94.9%). Co-morbid mental illness and/or substance misuse was common (55.7%). Reasons for admission included mental and behavioral disorders (overdose, alcohol withdrawal or depression, 28.3%), external causes of morbidity and mortality (assault or trauma, 18.7%), and injury, poisoning and external causes (head injury, falls and fractures, 12.4%). Unplanned Emergency Department attendances reduced after index admission and unplanned hospital admissions increased slightly. Planned admissions doubled and total bed days increased. Housing status was maintained or improved for over 60% of inpatients upon discharge. Within 12 months of index admission, 50 patients (5%) died, 15 deaths (30%) occurred during the index admission. Conclusions Disengagement with health services is common among homeless people. Many deaths are due to treatable medical conditions (heart disease, pneumonia, cancer). Observed increases in planned admissions suggests intervention from Pathway teams facilitates necessary investigations and treatment for homeless people. Equity, parity of care, and value should be inbuilt interventions for inclusion health groups and evaluations need to move beyond simply seeking cost reductions.
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Affiliation(s)
- Hannah Field
- Royal Surrey County Hospital, Egerton Road, Guildford, GU2 7XX, UK. .,Pathway, 250 Euston Road, London, NW1 2PG, UK.
| | - Briony Hudson
- Pathway, 250 Euston Road, London, NW1 2PG, UK.,Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | | | - Zana Khan
- Pathway, 250 Euston Road, London, NW1 2PG, UK.,UCL Collaborative centre for inclusion health, Department of Primary Care and Population Health, University College London, London, UK
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12
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Davies A, Wood LJ. Homeless health care: meeting the challenges of providing primary care. Med J Aust 2019; 209:230-234. [PMID: 30157413 DOI: 10.5694/mja17.01264] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/19/2018] [Indexed: 11/17/2022]
Abstract
People experiencing homelessness have multiple complex health conditions yet are typically disengaged from primary health care services and place a significant burden on the acute health system. Barriers preventing people who are homeless from accessing primary care can be both personal and practical and include competing needs and priorities, illness and poor health, physical access to health services, difficulty in contacting services, medication security, and the affordability of health care. Differences in social status and perceptions of being judged can lead to relationship barriers to accessing primary care. Key solutions include prioritising access to stable housing, continuity of health care, specialised homeless general practice, hospital inreach, discharge planning and coordinated care, general practice outreach, and medical recovery centres.
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Cornes M, Whiteford M, Manthorpe J, Neale J, Byng R, Hewett N, Clark M, Kilmister A, Fuller J, Aldridge R, Tinelli M. Improving hospital discharge arrangements for people who are homeless: A realist synthesis of the intermediate care literature. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:e345-e359. [PMID: 28730744 DOI: 10.1111/hsc.12474] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/19/2017] [Indexed: 06/07/2023]
Abstract
This review presents a realist synthesis of "what works and why" in intermediate care for people who are homeless. The overall aim was to update an earlier synthesis of intermediate care by capturing new evidence from a recent UK government funding initiative (the "Homeless Hospital Discharge Fund"). The initiative made resources available to the charitable sector to enable partnership working with the National Health Service (NHS) in order to improve hospital discharge arrangements for people who are homeless. The synthesis adopted the RAMESES guidelines and reporting standards. Electronic searches were carried out for peer-reviewed articles published in English from 2000 to 2016. Local evaluations and the grey literature were also included. The inclusion criteria was that articles and reports should describe "interventions" that encompassed most of the key characteristics of intermediate care as previously defined in the academic literature. Searches yielded 47 articles and reports. Most of these originated in the UK or the USA and fell within the realist quality rating of "thick description". The synthesis involved using this new evidence to interrogate the utility of earlier programme theories. Overall, the results confirmed the importance of (i) collaborative care planning, (ii) reablement and (iii) integrated working as key to effective intermediate care delivery. However, the additional evidence drawn from the field of homelessness highlighted the potential for some theory refinements. First, that "psychologically informed" approaches to relationship building may be necessary to ensure that service users are meaningfully engaged in collaborative care planning and second, that integrated working could be managed differently so that people are not "handed over" at the point at which the intermediate care episode ends. This was theorised as key to ensuring that ongoing care arrangements do not break down and that gains are not lost to the person or the system vis-à-vis the prevention of readmission to hospital.
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Affiliation(s)
- Michelle Cornes
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Martin Whiteford
- Health Services Research, University of Liverpool, Liverpool, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, King's College London, London, UK
| | - Richard Byng
- Clinical Trials and Health Research, University of Plymouth, Plymouth, UK
| | - Nigel Hewett
- Pathway, University College Hospital Homeless Team, London, UK
| | - Michael Clark
- The London School of Economics & Political Science, London, UK
| | - Alan Kilmister
- Social Care Workforce Research Unit, King's College London, London, UK
| | - James Fuller
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Robert Aldridge
- Public Health Informatics, University College London, London, UK
| | - Michela Tinelli
- The London School of Economics & Political Science, London, UK
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15
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Ann Webb W, Mitchell T, Nyatanga B, Snelling P. Nursing management of people experiencing homelessness at the end of life. Nurs Stand 2018; 32:53-63. [PMID: 29488729 DOI: 10.7748/ns.2018.e11070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2018] [Indexed: 11/09/2022]
Abstract
Homelessness is a complex and multidimensional issue often involving a combination of personal vulnerability, the limitations of social housing, and inadequacies in welfare support. Providing palliative and end-of-life care to people experiencing homelessness is challenging, both to individuals receiving care and nurses aiming to meet their complex needs. This article discusses what is understood by the concept of 'homelessness' and examines the barriers to accessing effective healthcare for people who are homeless and have life-limiting conditions. The authors review the research into end of life care for people experiencing homelessness and identify areas for further investigation, notably the lack of evidence regarding the end of life care priorities of these individuals. There is a focus on the availability of healthcare services for people who are homeless at the end of life, as well as the factors that should be considered if evidence-based healthcare services for this group of people are to be improved in the future.
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Affiliation(s)
- Wendy Ann Webb
- Institute of Health and Society, St John's Campus, University of Worcester, Worcester, England
| | - Theresa Mitchell
- Institute of Health and Society, St John's Campus, University of Worcester, Worcester, England
| | - Brian Nyatanga
- Institute of Health and Society, St John's Campus, University of Worcester, Worcester, England
| | - Paul Snelling
- Institute of Health and Society, St John's Campus, University of Worcester, Worcester, England
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Hudson BF, Flemming K, Shulman C, Candy B. Challenges to access and provision of palliative care for people who are homeless: a systematic review of qualitative research. BMC Palliat Care 2016; 15:96. [PMID: 27912748 PMCID: PMC5135820 DOI: 10.1186/s12904-016-0168-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/10/2016] [Indexed: 12/02/2022] Open
Abstract
Background People who are homeless or vulnerably housed are a marginalized group who often experience high rates of morbidity and die young as a result of complex problems. Access to health care and support can be challenging, with access to palliative care even more so. This review presents a synthesis of published qualitative research exploring from the perspective of homeless people and those working to support them, current challenges to palliative care access and provision, in addition to suggestions for what may improve palliative care for this population. Methods Systematic review of qualitative research analysed using thematic synthesis. PsycINFO, Medline, Sociological Abstracts, Social Services Abstracts, Science citations index and CINAHL were searched up to September 2016. Thematic synthesis involved a three-step inductive process to develop a deeper understanding of the challenges to and suggestions for the access and provision of palliative care for homeless people. Results Thirteen qualitative articles, reporting nine studies were identified. The challenges to access and provision to palliative care were drawn from the data covering three broad areas, namely “the chaotic lifestyles sometimes associated with being homeless”, “the delivery of palliative care within a hostel for homeless people” and provision within “mainstream health care systems”. Obstacles were related to homeless persons competing day-to-day priorities, their experience of stigma in mainstream settings, the high burden on hostel staff in supporting residents at the end of life and inflexibility in mainstream health care systems. Suggestions for improving access to palliative care include building trust between homeless persons and health professionals, increasing collaboration between and flexibility within services, and providing more training and support for all professionals. Conclusions The provision of palliative care can be complicated for all populations, however delivering palliative care for people who are homeless is influenced by a potentially greater and more varied range of factors, on both individual and systemic levels, than providing palliative care for the housed population. Careful consideration and potentially great changes will be needed within health care systems to ensure homeless populations have equitable access to palliative care.
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Affiliation(s)
- Briony F Hudson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK. .,Pathway, London, UK.
| | - Kate Flemming
- Department of Health Sciences, The University of York, York, UK
| | | | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
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