Addressing
root causes of homelessness will be key to driving patient care access with
this population.
By Sara Heath
March 18,
2019 - As healthcare organizations continue to drive strong
population health management, they must work to meet the medical and social
needs of their homeless populations. In doing so, they can help improve patient
care access for patients experiencing homelessness.
According to the
American Academy of Family Physicians (AAFP), patients experiencing
homelessness span a broad range of circumstances.
“Homeless persons are
individuals without permanent housing who may live on the streets; may stay in
a shelter, mission, single room occupancy facility, abandoned building, or
vehicle; or who are in any other unstable or nonpermanent situation,” the
organization wrote in a resource on
health and homelessness.
“Persons may be
considered homeless if circumstances force them to stay with a series of
friends or extended family members, or if they have been released from prison
or the hospital and do not have a stable housing situation to which they can
return.”
As of December 2018,
553,000 individuals experienced homelessness across the country, according to the Department of
Housing and Urban Development (HUD). And with that extraordinary number comes
significant health issues.
Patients experiencing
homelessness suffer from the same chronic conditions as patients who are not
homeless. However, it is more difficult for them to manage these conditions and
access healthcare. Additionally, patients experiencing homelessness experience
acute health concerns that are worse and more frequent than patients who are
not homeless.
Adults who are
homeless tend to die at a younger age than those who are not homeless, AAFP
reported. Pediatric patients who are homeless tend to face obstacles in school
and other areas of their lives, which can also hinder their health down the
line.
Homelessness is a
key social determinant of health that
creates vast differences in how patients experience their care. Patients
experiencing homelessness often struggle to access their care and coordinate
with their healthcare providers.
Because homeless
patients can be more costly to healthcare organizations and due to their
heightened needs, medical professionals should consider the various strategies
to connect this population to care. Instituting team-based care and community
health strategies may help drive patient care access for homeless populations.
IDENTIFYING
PATIENTS WHO ARE HOMELESS
The first step to
enhancing care for homeless patients is identifying them. This should happen
during initial primary care visits, according to the AAFP.
“The physician and
clinic staff should focus on demonstrating genuine interest, empathy, and
respect in a warm, nonthreatening, nonjudgmental environment,” the organization
said.
Providers may start
by addressing the symptoms the patients have presented with and offering
effective health solutions that will impact the patient’s day-to-day life.
“This will help to
establish confidence and mutual trust and encourage the patient to return to
the physician's office,” AAFP wrote. “Once trust and rapport are established,
visits can focus on identifying an emergency contact and discussing the
patient's more challenging social, medical, and mental health problems, and
end-of-life issues.”
Healthcare
organizations must institute the best systems to keep track of these patients.
This will help drive follow-ups with the patient and allow other providers to
understand the patient’s circumstances.
“Data is a big piece
of this, too. Just figuring out who's homeless in our patient
population,” explained Stephen Brown, who is
Director of Preventive Emergency Medicine at the University of Illinois Health
(UI Health). “It's significantly under-reported and that's one of the things
we're advocating for – better reporting of homelessness. It's not coded right
now very well.”
Using the above
techniques to discover who may be experiencing homelessness and then entering
that information into the EHR will be crucial. That will allow doctors to view
who is homeless and refer those patients to the right services, Brown said. It
will also tip doctors off to which patients may need different types of chronic
care services.
UTILIZING
TEAM-BASED CARE FOR HOMELESS PATIENTS
Team-based care is
touted as the gold standard for all patient
populations, but it will be especially crucial for treating homeless patients.
Team-based care strategies will ensure all providers are able to care for
patients and will help target patients who access care unpredictably.
“An integrated,
multidisciplinary health care team with an outreach focus, along with
involvement of local and state agencies, seems best suited to address the
components needed to ensure quality of care, to help make these patients self-sufficient,
and to help them succeed,” AAFP explained. “Family physicians are well suited
to manage the needs of the homeless patient, provide continuity of care, and
lead these multidisciplinary teams.”
Care teams should
include family physicians, hospital-based providers, as well as community
health specialists and case workers.
Furthermore,
healthcare teams may consider reworking care plans for patients who are
homeless. This population is often difficult to get in touch with or locate,
meaning it will be challenging to engage in follow-up care for these patients.
Setting up short-term care goals will make it easier for physicians to track
patient progress and be more engaging for the patient, AAFP noted.
A strong community
presence will aid in carrying out care plans for homeless patients. Meeting the
patient where they are will increase the likelihood that patients receive
follow-up care, or at least the preventive care that will keep them healthier
in the long run.
Mobile health clinics allow patients
to visit providers where it is more convenient for them, allowing healthcare
organizations to touch base with patients. Setting up school-based clinicscan address needs for
pediatric patients.
Additionally,
community outreach programs at homeless shelters, food banks, employment
offices, and other locations help patients connect with care.
“Multidisciplinary
teams can also co-locate medical, mental health, and addictions services,
coordinate vertical integration of components within the health care system
(such as the clinic, health center, emergency department, and hospital), and
facilitate horizontal integration with other key sectors, including the criminal
justice system, after-jail services, social services, and housing,” researchers
Howard K. Koh, MD, MPH and James J. O’Connell, MD
wrote in a 2016 JAMA piece.
USING
HOUSING FIRST TO ADDRESS HOMELESS POPULATIONS
While it is important
to treat the medical issues homeless populations present with, it will be more
important to address housing stability as a root cause of these conditions.
Housing first
programs, which call on hospitals and health systems to address housing as a
medical condition, have proven effective where implemented. Building off those
successes, organizations across the country are working with community health partners to create
more affordable housing options and connect their populations with them.
These programs are
admittedly difficult and expensive to manage. But they have significant
clinical payoff, according to UI Health’s Brown.
“If you begin to wear
a lens of thinking that it's a dangerous health condition, then it just makes
sense that hospitals would want to go beyond what they typically do, beyond
delivering excellent medical care, and really move into a population health
space,” Brown asserted.
But when an
organization invests in housing, it ideally cuts costs driven by this complex
population.
“A lot of hospitals
were concerned about the plummeting rates of uncompensated care they have, and
they were nervous that the IRS was going to scrutinize them because of
community health needs assessment findings,” Brown concluded. “This is a good
program for hospitals to feel good about themselves, that they're actually
impacting the health of the residents in the community that they serve.”
As healthcare
organizations continue their population health management strategies, they must
acknowledge both the medical and community health components. While treating
the symptoms and health needs of populations will be key, as will be addressing
the social determinants of health with community health programming.
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