Determinants of Implementation of a Clinical Practice Guideline for Homeless Health

Abstract

Clinical practice guidelines can improve the clinical and social care for marginalized populations, thereby improving health equity. The aim of this study is to identify determinants of guideline implementation from the perspective of patients and practitioner stakeholders for a homeless health guideline. We completed a mixed-method study to identify determinants of equitable implementation of homeless health guidelines, focusing on the Grading of Recommendations Assessment, Development and Evaluation Feasibility, Acceptability, Cost, and Equity Survey (GRADE-FACE) health equity implementation outcomes. The study included a survey and framework analysis. Eighty-eight stakeholders, including practitioners and 16 persons with lived experience of homelessness, participated in the study. Most participants favourably rated the drafted recommendations’ priority status, feasibility, acceptability, cost, equity impact, and intent-to-implement. Qualitative analysis uncovered stakeholder concerns and perceptions regarding “fragmented services”. Practitioners were reluctant to care for persons with lived experience of homelessness, suggesting that associated social stigma serves as a barrier for this population to access healthcare. Participants called for improved “training of practitioners” to increase knowledge of patient needs and preferences. We identified several knowledge translation strategies that may improve implementation of guidelines for marginalized populations. Such strategies should be considered by other guideline development groups who aim to improve health outcomes in the context of limited and fragmented resources, stigma, and need for advocacy.

Identifying Challenges and Solutions to Providing Diabetes Care for Those Experiencing Homelessness

“…These recommendations acknowledge the necessity of providing wraparound services in the primary care environment. The provision of housing is commonly regarded in the literature as the highest yield intervention for improving healthcare in individuals experiencing homelessness, which is also consistent with our findings (Magwood et al, 2020).…”

“…These services have been incorporated successfully using a "one-stop-shop" strategy for different types of health and social care, or through the use of an outreach model of care. This concept was reported as a strength of many healthcare interventions targeted to individuals experiencing homelessness (Kertesz et al, 2021;Luchenski et al, 2018;Magwood et al, 2020). In a program serving veterans who are homeless, comparing regular health services to an integrated program that included primary care, social services, and mental health services demonstrated that patients who attended the integrated service had higher usage of primary care services and reduced usage of emergency services (McGuire et al, 2009).…”

Connections and Biases in Health Equity and Culture Research: A Semantic Network Analysis

“…For example, people experiencing homelessness or vulnerable housing are often marginalized and are known to face barriers to accessing appropriate healthcare services ( 9 ). Although changes have been recommended in the complex health systems, so that it should be more equitable, more sensitive and empathic, and more informed about the traumatic situations experienced by homeless people, barriers related to cultural aspects are barely mentioned in those key documents ( 116 – 118 ). Similar patterns can be seen in the studies of other conditions of vulnerability and adverse circumstances that apparently seem disconnected from their own cultural aspects or they seem irrelevant for health equity ( 119 ).…”

Specialist medical centres for the homeless in Hamburg - diagnoses and reasons for treatment compared to general practice system (regular care system)

“…Due to the milieu-speci c characteristics affecting the care and treatment of homeless people, guidelines should be developed to support doctors in their diagnostic and therapeutic approach. Magwood et al (2020) [28] developed criteria for "Clinical Practice Guideline for Homeless Health" which address the upstream social and health needs, as well as the downstream health consequences of inadequate housing. Speci cally, the kind of interventions indicated include the provision of supportive housing, income support and case management.…”