Identifying homeless population needs in the Emergency Department using Community-Based Participatory Research

Abstract

Background Annually 1.5 million Americans face housing insecurity, and compared to their domiciled counterparts are three times more likely to utilize the Emergency Department (ED). Community Based Participatory Research (CBPR) methods have been employed in underserved populations, but use in the ED has been limited. We employed CBPR in an urban American hospital with a primary goal of improved linkage to care, reduced ED recidivism, and improved homeless health care. Methods A needs analysis was performed using semi-structured individual interviews with participants experiencing homelessness as well as with stakeholders. Results were analyzed using principles of grounded theory. At the end of the interviews, respondents were invited to join the “CBPR team”. At CBPR team meetings, results from interviews were expounded upon and discussions on intervention development were conducted. Results Twenty-five stakeholders were interviewed including people experiencing housing insecurity, ED staff, inpatient staff, and community shelters and services. Three themes emerged from the interviews. First, the homeless population lack access to basic needs, thus management of medical needs must be managed alongside social ones. Second, specific challenges to address homeless needs in the ED include episodic care, inability to recognize housing insecurity, timely involvement of ancillary staff, and provider attitudes towards homeless patients affecting quality of care. Lastly, improved discharge planning and communication with outside resources is essential to improving homeless health and decreasing ED overutilization. A limitation of results is difficulty for participants experiencing homelessness to commit to regular CBPR meetings, as well as possible bias towards social networks influencing included stakeholders. Conclusion CBPR is a promising approach to address gaps in homeless health care as it provides a comprehensive view incorporating various critical perspectives. Key ED-based interventions addressing recidivism include improved identification of housing insecurity, reinforced relationships between ED and community resources, and better discharge planning.

Experiences of Adult Men Who Are Homeless Accessing Care: A Qualitative Study

“…These results complement the existing body of literature on the experience of homeless individuals accessing health care (Franco et al, 2021;Martins, 2008;O'Carroll & Wainwright, 2019;Omerov et al, 2020;Ramsay et al, 2019). With homeless service programs prioritizing housing first (Tsai et al, 2017), homeless individuals in this study experienced access to health care as transactional.…”

“…The third theme, Care Coordination Resources Are Inadequate, reflects the SDOH that negatively affect the health of homeless individuals (Doran et al, 2016;Franco et al, 2021). SDOH complicate traditional approaches to care planning; thus, they can be insufficient to meet their needs.…”

“…Law and John (2012) argue that homelessness, using transcultural theory, can be viewed as a culture based on the shared beliefs, norms, and patterns of living that exist among homeless populations. Homeless individuals must navigate a web of social determinants of health (SDOH) to receive care (Doran et al, 2016;Franco et al, 2021). The narrative experience of homeless individuals serves as a necessary consideration when designing interventions to improve health and reduce disparities for this population.…”

Multistage Psychometric Testing of the Homeless Health Access to Care Tool

“…Acknowledging that emergency departments are extremely busy, and the tempo of practice means that tackling the often-complex issues facing people experiencing homelessness can be highly challenging. People experiencing homelessness have reported that they leave the emergency department having had very few of their needs met [ 23 ].…”

“…There is debate as to the role that emergency departments can have in interrupting the cycle of homelessness. Proponents argue that because most people experiencing homelessness access emergency department care, their attendance is an opportunity not to be missed to link this vulnerable population with healthcare and other services [ 23 , 24 ]. Yet, evidence suggests that some emergency departments are under resourced to meet the myriad of health and social needs of people experiencing homelessness [ 25 ].…”