Priorities in the primary care of persons experiencing homelessness: convergence and divergence in the views of patients and provider/experts

Abstract

PurposeHomeless individuals face unique challenges in health care. Several US initiatives seeking to advance patient-centered primary care for homeless persons are more likely to succeed if they incorporate the priorities of the patients they are to serve. However, there has been no prior research to elicit their priorities in primary care. This study sought to identify aspects of primary care important to persons familiar with homelessness based on personal experience or professional commitment, and to highlight where the priorities of patients and professionals dedicated to their care converge or diverge.MethodsThis qualitative exercise asked 26 homeless patients and ten provider/experts to rank 16 aspects of primary care using a card sort. Patient-level respondents (n=26) were recruited from homeless service organizations across all regions of the USA and from an established board of homeless service users. Provider/expert-level respondents (n=10) were recruited from veteran and non-veteran-focused homeless health care programs with similar geographic diversity.ResultsBoth groups gave high priority to accessibility, evidence-based care, coordination, and cooperation. Provider/experts endorsed patient control more strongly than patients. Patients ranked information about their care more highly than provider/experts.ConclusionAccessibility and the perception of care based on medical evidence represent priority concerns for homeless patients and provider/experts. Patient control, a concept endorsed by experts, is not strongly endorsed by homeless patients. Understanding how to assure fluid communication, coordination, and team member cooperation could represent more worthy targets for research and quality improvement in this domain.

A national evaluation of homeless and nonhomeless veterans’ experiences with primary care.

“…In a prior study that included a small sample (n=26) of homeless individuals, researchers found that homeless persons gave high priority to service accessibility, care coordination, and cooperation between patients and providers in the context of their primary care settings (Steward et al, 2016). VHA’s PACT initiative aims to facilitate care coordination through frequent PACT team meetings, and by having PACT members oversee care transitions to specialty care providers.…”

“…Indeed, patient involvement with medication decision-making has been shown to improve treatment adherence and outcomes for chronic medical and mental health conditions (Bauer et al, 2014). In addition, homeless persons greatly value more information provided about their care (Steward et al, 2016). In the movement towards patient-centered care, our results indicate that solutions are needed to help all Veterans participate in treatment decision and health management.…”

“…Several factors have been identified as contributing to homeless Veterans’ underutilization of primary care services, including lack of transportation, insurance, and a usual source of care, and presences of competing priorities (Chwastiak, Tsai, & Rosenheck, 2012; Gelberg, Andersen, & Leake, 2000; Gelberg, Gallagher, Andersen, & Koegel, 1997; Kushel, Vittinghoff, & Haas, 2001; Steward et al, 2016). Another critical factor that affects homeless persons’ primary care service use is negative perceptions of how homeless persons were treated by healthcare providers and their perceptions of the healthcare environment (Mason, Jensen, & Boland, 1992; O’Toole, Johnson, Redihan, Borgia, & Rose, 2015; Steward et al, 2016; Wen, Hudak, & Hwang, 2007).…”

“…Another critical factor that affects homeless persons’ primary care service use is negative perceptions of how homeless persons were treated by healthcare providers and their perceptions of the healthcare environment (Mason, Jensen, & Boland, 1992; O’Toole, Johnson, Redihan, Borgia, & Rose, 2015; Steward et al, 2016; Wen, Hudak, & Hwang, 2007). For example, homeless persons participating in qualitative interviews have reported feeling unwelcome (Wen et al, 2007) and being treated with prejudice in health care settings (Rae & Rees, 2015).…”

“…National investigations of healthcare experiences among patients with MHSUDs (e.g., patient perceptions of the accessibility of needed services, provider communication skills, and office staff helpfulness/courtesy) have not reported on findings for homeless persons (Burnett-Zeigler, Zivin, Ilgen, Islam, & Bohnert, 2011; Jones et al, 2016; Kilbourne et al, 2006). Studies focused on homeless persons’ experiences have been restricted to a small number of clinics (Chrystal et al, 2015; Zerger et al, 2014), have lacked a non-homeless comparison group (Kertesz et al, 2014), had small samples (Steward et al, 2016), or did not assess patient experiences with care in domains relevant to MHSUD care (e.g., comprehensiveness, care coordination, medication decision-making) (Lebrun-Harris et al, 2013). This is a notable gap in the literature considering that homeless persons disproportionately suffer from MHSUDs and patient experiences with care in general outpatient settings affect MHSUD service use and clinical outcomes (Bauer et al, 2014; Kim et al, 2007; True, Rigg, & Butler, 2015).…”