The Effect of Homelessness on Patient Wait Times in the Emergency Department

Examining the experiences of vulnerably housed patients visiting Kingston, Ontario's emergency departments: a qualitative analysis

INTRODUCTION

Vulnerably housed individuals access emergency departments (EDs) more frequently than the general population. Despite Canada's universal public health care system, vulnerably housed persons face structural barriers to care and experience discrimination from healthcare providers. This study examines how vulnerably housed persons perceive their experience of care in the ED and Urgent Care Center (UCC) in Kingston, Ontario and aims to develop strategies for improving care for this group.

METHODS

As part of a larger mixed-methods study, narratives were collected from participants attending the ED/UCC as well as community-based partner organizations, asking them to describe an experience of a recent ED visit (< 24 months). Participants could identify as members of up to three equity-deserving groups (EDGs) (for example homeless, part of an ethnic minority, having a disability, experiencing mental health issues). Coding and thematic analysis were completed for the experiences of participants who identified as being vulnerably housed (n = 171). Results were presented back to individuals with lived experience and service providers working with clients with unstable housing.

RESULTS

Participants reported judgement related to a past or presumed history of mental health or substance use and based on physical appearance. They also often felt unheard and that they were treated as less than human by healthcare providers. Lack of effective communication about the ED process, wait times, diagnosis, and treatment led to negative care experiences. Participants reported positive experiences when their autonomy in care-decision making was respected. Furthermore, having a patient-centered approach to care and addressing specific patient needs, identities and priorities led to positive care experiences.

CONCLUSIONS

The ED care experiences of vulnerably housed persons may be improved through healthcare provider training related to trauma-informed and patient-centered care and communication strategies in the ED. Another potential strategy to improve care is to have advocates accompany vulnerably housed persons to the ED. Finally, improving access to primary care may lead to reduced ED visits and better longitudinal care for vulnerably housed persons.

Homelessness and Emergency Department Use: Wait Time Disparities Across Triage Acuity Levels

Introduction Certain patient groups perceive specific barriers to accessing primary care, resulting in increased emergency department (ED) use for non-emergency conditions. There is evidence coming from other countries that homeless people are treated differently in accessing emergency services. Examination of ED wait time by demographic characteristics provides pertinent information to identify subgroups that are more subject to the consequences or causes of access block and delayed treatment.  Methods We analyzed five years of Emergency Department Information System (EDIS) visit records of the largest tertiary care center in Atlantic Canada. The wait time from triage to seeing a physician was the outcome, housing status was the main exposure, and age and gender were the predictors. Quantile regressions were carried out to identify the influence of homeless visits in meeting the Canadian Association of Emergency Physicians (CAEP) wait time benchmarks for each Canadian Triage and Acuity Scale (CTAS) level. The classification and regression tree method was used to quantify and classify the demographic subgroups contributing to wait time disparities across CTAS levels. Results Homeless visit median wait times that exceeded the three-hour CAEP benchmark were significantly longer for urgent (by 40 minutes, CI: 25-55), semi-urgent (by 31 minutes, CI: 17-45), and non-urgent (by 57 minutes, CI: 25-89) than acuity level-matched domiciled visit wait times. At the 50th percentile, one-hour benchmark homeless triaged as semi-urgent waited (median=20 minutes, CI: 12-28) longer, and no other triage-level differences were found at this benchmark. Homeless emergent-level visits that exceeded the three-hour benchmark were 28 minutes, on average, shorter than domiciled patients of the same acuity level. Homeless females above 40 stayed the longest for non-urgent care (mean=173 minutes), 82 minutes longer (p=0.0001) than age-gender-acuity level-matched domiciled patients. Homelessness was the most prominent ED wait time classifier for non-urgent, ED visits. Overall, homeless patients triaged as CTAS-5 waited 30 minutes longer (p=0.0001) than domiciled patients triaged as CTAS-5. Homeless male 16-20-year-olds waited the shortest time of 72 minutes.  Conclusion Homelessness-related wait time disparities exist in the low acuity non-urgent-level ED visits more than in the other levels, supporting the theory that lack of primary care access is a driver of ED use in this group. Our acuity level analysis supports that homeless people of a certain age (older) and gender groups (female) wait longer than their age-gender-matched domiciled patients to be seen by a physician in low acuity level presentations. Given the pattern of the homeless being seen earlier or statistically similar in emergent-level visits compared to matched domiciled patients and that 16-20-year-old homeless males were seen on average within 72 minutes (the shortest mean wait time reported for the triage level CTAS-5), we decline the notion of discrimination at the study site ED. If homeless patients' non-urgent needs were met elsewhere, pressure on the ED to meet benchmarks might be reduced.

Optimizing Access to the COVID-19 Vaccination for People Experiencing Homelessness

The success of the Australian COVID-19 vaccination strategy rested on access to primary healthcare. People experiencing or at risk of homelessness are less likely to access primary healthcare services. Therefore, leaders in homeless health service delivery in Sydney identified the need to develop a vaccine hub specifically for this vulnerable population. The aim of this study was to develop an evidenced based model of care to underpin the Vaccine Hub and optimize access to vaccination for people experiencing or at risk of homelessness. A mixed methods study was conducted that included interviews with key stakeholders involved in establishing and delivering the Inner City COVID-19 Vaccine Hub, and a survey with people receiving COVID-19 vaccination. Over the 6-month period of this study, 4305 COVID-19 vaccinations were administered. Participants receiving vaccination reported feeling safe in the Vaccine Hub and would recommend it to others. Stakeholders paid tribute to the collective teamwork of the Vaccine Hub, the collaboration between services, the 'no wrong door' approach to increasing access and the joy of being able to support such a vulnerable population in challenging times. The study findings have been populated into a Vaccination Hub Blueprint document that can be used as a template for others to improve access to vaccinations for vulnerable populations.

Scoping review: Scope of practice of nurse-led services and access to care for people experiencing homelessness

AIMS

To investigate the scope of practice of nurse-led services for people experiencing homelessness, and the influence on access to healthcare.

DESIGN

A scoping review.

DATA SOURCES

On 20 November 2020, the following databases were searched: CINAHL, Embase, MEDLINE, PubMed and Scopus.

REVIEW METHODS

Included studies focused on people experiencing homelessness aged 18 years and over, nurse-led services in any setting and described the nursing scope of practice. Studies were peer-reviewed primary research, published in English from the year 2000. Three authors performed quality appraisals using the mixed methods assessment tool. Results were synthesized and discussed narratively and reported according to the PRISMA-ScR 2020 Statement.

RESULTS

Nineteen studies were included from the United States (n = 9), Australia (n = 4), United Kingdom (n = 4) and Canada (n = 2). The total participant sample size was n = 6303. Studies focused on registered nurses (n = 10), nurse practitioners (n = 5) or both (n = 4), in outpatient or community settings. The nursing scope of practice was broad and covered a range of skills, knowledge and attributes. Key skills identified include assessment and procedural skills, client support and health education. Key attributes were a trauma-informed approach and building trust through communication. Important knowledge included understanding the impact of homelessness, knowledge of available services and the capacity to undertake holistic assessments. Findings suggest that nurse-led care facilitated access to healthcare through building trust and supporting clients to access services.

CONCLUSION

Optimized nursing scope of practice can facilitate access to healthcare for people experiencing homelessness. Key factors in enabling this include autonomy in nursing practice, organizational support and education.

IMPACT

The broad range of skills, knowledge and attributes reported provide a foundation from which to design an educational framework to optimize the nursing scope of practice, thereby increasing access to healthcare for people experiencing homelessness.

Development of the Homeless Health Access to Care Tool to identify health-related vulnerability among people experiencing homelessness: Delphi study, Australia

OBJECTIVES

In this paper, we report the development of the Homeless Health Access to Care Tool. This tool aims to improve the gap in assessing health need and capacity to access healthcare of people experiencing homelessness. Tools exist that prioritise people experiencing homelessness for housing, but none specifically designed to prioritise for healthcare, or that are succinct enough to be easily implemented to emergency department or primary healthcare settings.

DESIGN AND SETTING

The Homeless Health Access to Care Tool has been adapted from an existing tool, the Vulnerability Index Service Prioritisation Decision Assistance Tool through a five-step process: (1) domain identification, (2) literature review, (3) analysis of hospital admission data, (4) expert judges, and (5) Delphi study.

PARTICIPANTS

The tool was adapted and developed by homeless health clinicians, academics and people with lived experience of homelessness. The Delphi study (n=9) comprised emergency department and homeless health clinicians.

RESULTS

Consensus was gained on all but one item, five new items were added, and wording changes were made to six items based on expert feedback. Participants perceived the tool would take between 5 to 11 min to complete, the number of items were appropriate, and the majority agreed it would facilitate the assessment of health needs and capacity to access healthcare.

CONCLUSION

Robust development of the Homeless Health Access to Care Tool through the Delphi is the first phase of its development. The Homeless Health Access to Care Tool offers an opportunity to assess both health need and capacity to access healthcare with the aim to improve access to healthcare for people experiencing homelessness. This tool will facilitate standardised data collection to inform service design and data linkage regarding access to healthcare of people experiencing homelessness. The next stages of testing include construct validity, feasibility, usability and inter-rater reliability, and pilot implementation.