From Homeless to Housed: Caring for People in Transition

Improving care transfers for homeless patients after hospital discharge: a realist evaluation

Background

In 2013, 70% of people who were homeless on admission to hospital were discharged back to the street without having their care and support needs addressed. In response, the UK government provided funding for 52 new specialist homeless hospital discharge schemes. This study employed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines between September 2015 and 2019 to undertake a realist evaluation to establish what worked, for whom, under what circumstances and why. It was hypothesised that delivering outcomes linked to consistently safe, timely care transfers for homeless patients would depend on hospital discharge schemes implementing a series of high-impact changes (resource mechanisms). These changes encompassed multidisciplinary discharge co-ordination (delivered through clinically led homeless teams) and ‘step-down’ intermediate care. These facilitated time-limited care and support and alternative pathways out of hospital for people who could not go straight home.

Methods

The realist hypothesis was tested empirically and refined through three work packages. Work package 1 generated seven qualitative case studies, comparing sites with different types of specialist homeless hospital discharge schemes (n = 5) and those with no specialist discharge scheme (standard care) (n = 2). Methods of data collection included interviews with 77 practitioners and stakeholders and 70 people who were homeless on admission to hospital. A ‘data linkage’ process (work package 2) and an economic evaluation (work package 3) were also undertaken. The data linkage process resulted in data being collected on > 3882 patients from 17 discharge schemes across England. The study involved people with lived experience of homelessness in all stages.

Results

There was strong evidence to support our realist hypothesis. Specialist homeless hospital discharge schemes employing multidisciplinary discharge co-ordination and ‘step-down’ intermediate care were more effective and cost-effective than standard care. Specialist care was shown to reduce delayed transfers of care. Accident and emergency visits were also 18% lower among homeless patients discharged at a site with a step-down service than at those without. However, there was an impact on the effectiveness of the schemes when they were underfunded or when there was a shortage of permanent supportive housing and longer-term care and support. In these contexts, it remained (tacitly) accepted practice (across both standard and specialist care sites) to discharge homeless patients to the streets, rather than delay their transfer. We found little evidence that discharge schemes fired a change in reasoning with regard to the cultural distance that positions ‘homeless patients’ as somehow less vulnerable than other groups of patients. We refined our hypothesis to reflect that high-impact changes need to be underpinned by robust adult safeguarding.

Strengths and limitations

To our knowledge, this is the largest study of the outcomes of homeless patients discharged from hospital in the UK. Owing to issues with the comparator group, the effectiveness analysis undertaken for the data linkage was limited to comparisons of different types of specialist discharge scheme (rather than specialist vs. standard care).

Future work

There is a need to consider approaches that align with those for value or alliance-based commissioning where the evaluative gaze is shifted from discrete interventions to understanding how the system is working as a whole to deliver outcomes for a defined patient population.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 17. See the NIHR Journals Library website for further project information.

A Critical Ethnography of Outreach Nursing for People Experiencing Homelessness

People experiencing homelessness have a high prevalence of substance abuse and mental and physical problems. Although they have very complex health needs, they face many barriers that reduce their access to health care and social services. Several research studies have shown the need to implement adapted nursing interventions to address these crucial access issues. In this article, we present the results of a critical ethnography of outreach nurses who work with homeless people (n = 12). Robert Castel's theoretical model, which focuses on the process of social disaffiliation, provided the conceptual underpinnings for this research. Our qualitative data analysis revealed four categories, namely 1) the professional role and identity of nurses; 2) the social function of outreach nursing; 3) clinical realities and 4) disaffiliation and stigmatization. Our findings highlight the need to raise awareness among health care providers about the ethical, clinical and organizational issues of homelessness, particularly the mechanisms of exclusion and stigmatization in health care settings that affect people experiencing homelessness.

Le soutien postlogement transitoire auprès des femmes en situation d’itinérance : besoins, implantation et impact d’une étude pilote

Objectifs Les dispositifs de soutien en logement sont parmi les solutions soutenues pour contrer l’itinérance. Le logement transitoire (LT) offre une trajectoire séquentielle d’accès à la stabilité résidentielle : des refuges au LT, au logement permanent avec ou sans soutien. Le suivi post-LT permettrait d’améliorer la stabilité résidentielle et l’intégration communautaire. Néanmoins, peu d’informations sont disponibles sur les conditions de succès et la capacité du suivi post-LT à améliorer la stabilité résidentielle et l’intégration communautaire des personnes itinérantes, en particulier les femmes. Cette étude de cas pilote visait à identifier les besoins de femmes recevant du suivi post-LT, l’implantation des activités de suivi et ses conditions de succès, ainsi que son impact en réponse aux besoins exprimés.

Méthode Deux organismes à but non lucratif ont été sélectionnés à Montréal. Une étude de cas à partir de méthodes mixtes a permis de trianguler les données provenant de femmes en situation d’itinérance, de leurs intervenantes et des gestionnaires de ressources de suivi post-LT. Deux entretiens ont été menés à un intervalle de 6 mois avec ces femmes (n = 10). Les besoins et l’impact du suivi post-LT ont été mesurés grâce à un questionnaire (questions ouvertes et fermées). Pour documenter l’implantation du suivi, des informations ont été colligées auprès des intervenantes (n = 2) sur les activités et l’intensité des services offerts à l’aide de fiches de contact. Des facteurs facilitant et entravant le suivi post-LT ont également été identifiés lors d’une entrevue de groupe avec les intervenantes (n = 2) et les gestionnaires (n = 4).

Résultats Les usagères ont identifié des besoins liés à la santé, aux activités quotidiennes et à l’intégration sociale. La plupart des femmes étaient satisfaites des activités et de la fréquence du suivi, de la facilité d’accès des intervenantes et de la capacité du suivi à répondre à leurs besoins. L’intensité du suivi, l’alliance thérapeutique usagère/intervenante et la motivation des usagères ont été identifiées comme des facteurs facilitants. Les facteurs entravants comprenaient : la durée limitée de l’insertion préalable en LT, particulièrement chez les usagères ayant subi un traumatisme majeur ; les comportements réfractaires ; la réticence à prendre des médicaments et la dépendance à des substances psychoactives ; les problèmes d’accès aux services, dont les services de santé mentale spécialisés ; et pour les intervenantes, les contraintes de temps, les difficultés logistiques, et le manque de logements permanents abordables adéquats. Après six mois, 80 % des usagères avaient conservé le même logement, et leur intégration communautaire n’avait pas changé.

Conclusion Le suivi post-LT semble adapté pour promouvoir la stabilité résidentielle chez les femmes en situation d’itinérance chronique et ayant des problèmes de santé mentale ou de dépendance, première étape essentielle vers l’intégration communautaire. L’étude a souligné l’importance d’offrir des modalités de services adaptés aux besoins des usagères. Un meilleur financement du suivi post-LT, une collaboration plus étroite avec d’autres services publics, une formation accrue des intervenantes et une augmentation du nombre de logements permanents abordables et adéquats favoriseraient un déploiement plus efficace du suivi post-LT.

Healthcare professionals' perceptions of the implementation of the transitional discharge model for community integration of psychiatric clients

Research has demonstrated the benefits of mental healthcare interventions that ensure a safe transition of clients throughout the discharge and community integration process. This paper reports on qualitative data from focus groups with health professionals collected as part of a larger a mixed method study designed to examine the effectiveness and sustainability of implementing the transitional discharge model. Data collection involved two sets of focus groups, which were held at six months and one-year post-implementation. There were 216 health professional participants from nine (9) hospitals across the Province of Ontario, Canada. Data analysis used a four-step ethnographic framework by Leininger (1985) to identify descriptors and recurrent and major themes. The study identified four major themes, including healthcare professionals' roles and positive experiences in implementing the transitional discharge model; perceived benefits of the model; challenges to implementing the model; and suggestions for sustaining the model's implementation. Healthcare professionals felt that the implementation of the transitional discharge model has the potential for increasing their awareness of the process of clients' integration, serving as a framework for discharge planning, and reducing hospital readmissions. The study findings may provide healthcare providers with information on pragmatic ways to plan clients' discharge, to bridge the gap between hospital and community care, and to positively impact client health outcomes.

Health supports needed for homeless persons transitioning from hospitals

Being homeless has a negative effect on health and the health needs of individuals experiencing homelessness are complex and challenging to address. As a result of limited access to and use of primary healthcare, the main point of entry into the healthcare system for individuals experiencing homelessness is often hospitals and emergency departments. Persons experiencing homelessness are commonly discharged from hospital settings to locations that do not support recovery or access to follow-up care (e.g. shelters or the street). This can be costly to both the healthcare system and to individuals' health and quality of life. We conducted a scoping review of the literature published between 2007 and 2017 to identify the types of health supports needed for persons experiencing homelessness who are discharged from the hospital. Thirteen literature sources met inclusion criteria and thematic data analyses by two researchers resulted in the identification of six themes related to the types of health supports needed for persons experiencing homelessness who are transitioning (i.e. being discharged) from the hospital. Using a community consultation approach, the scoping review themes were validated with 23 health and shelter service providers and included in our integrated findings. Themes included: (a) a respectful and understanding approach to care, (b) housing assessments, (c) communication/coordination/navigation, (d) supports for after-care, (e) complex medical care and medication management, and (f) basic needs and transportation. These themes were found to resonate with participants of the community consultation workshop. Recommendations for trauma-informed care and patient- or client-centred care approaches are discussed.

Homelessness at discharge and its impact on psychiatric readmission and physician follow-up: a population-based cohort study

AIMS

A significant proportion of adults who are admitted to psychiatric hospitals are homeless, yet little is known about their outcomes after a psychiatric hospitalisation discharge. The aim of this study was to assess the impact of being homeless at the time of psychiatric hospitalisation discharge on psychiatric hospital readmission, mental health-related emergency department (ED) visits and physician-based outpatient care.

METHODS

This was a population-based cohort study using health administrative databases. All patients discharged from a psychiatric hospitalisation in Ontario, Canada, between 1 April 2011 and 31 March 2014 (N = 91 028) were included and categorised as homeless or non-homeless at the time of discharge. Psychiatric hospitalisation readmission rates, mental health-related ED visits and physician-based outpatient care were measured within 30 days following hospital discharge.

RESULTS

There were 2052 (2.3%) adults identified as homeless at discharge. Homeless individuals at discharge were significantly more likely to have a readmission within 30 days following discharge (17.1 v. 9.8%; aHR = 1.43 (95% CI 1.26-1.63)) and to have an ED visit (27.2 v. 11.6%; aHR = 1.87 (95% CI 1.68-2.0)). Homeless individuals were also over 50% less likely to have a psychiatrist visit (aHR = 0.46 (95% CI 0.40-0.53)).

CONCLUSION

Homeless adults are at higher risk of readmission and ED visits following discharge. They are also much less likely to receive post-discharge physician care. Efforts to improve access to services for this vulnerable population are required to reduce acute care service use and improve care continuity.

Safe Spaces, Agency, and Connections to “Regular Stuff”: What Makes Permanent Supportive Housing Feel Like “Home”

Permanent, supportive housing for people with a history of homelessness is often a first step toward regaining stability in other life areas, but such housing may not always feel like “home.” Whether supportive housing feels like “home” has received increasing attention due to links with positive identity reconstruction, housing stability, and improved community engagement. This qualitative study explored what makes supportive housing feel like “home” for individuals who were once homeless. Semi-structured interviews were completed among 37 adults with physical and/or psychiatric disabilities who were currently living in congregate or independent permanent housing in Boston, Massachusetts. Three themes emerged regarding what makes housing feel like “home”: (a) safe spaces, (b) connections to “regular stuff” and past occupations, and (c) agency to choose and pursue personal goals. Feelings of “home” were associated with a safe, peaceful environment where participants preferred to spend time in solitary activities. However, housing that felt like “home” also provided a base to engage in daily routines and community activities, reconnecting participants to “everyday things people do.” Findings are interpreted related to constructing a new, nonhomeless identity, and current issues of social isolation and limited community integration affecting individuals who were once homeless.

A qualitative exploration of nursing students' perceptions of the homeless and their care experiences

The health care needs of the homeless are more complex than those of the population at large. The purpose of this qualitative study was to explore undergraduate nursing students' perceptions of the homeless. Thematic content analysis of responses from 19 undergraduate nursing students yielded four themes describing student experiences with the homeless, their perceptions of homelessness and the health care of the homeless, and their suggestions for best teaching strategies. Students in this study had varying amounts of experience with and knowledge of the homeless. While our participants strongly believed that homeless people deserved compassionate, equitable nursing care, many of their statements suggested an implicit bias toward the homeless. This suggests that student nurses need more comprehensive education concerning the homeless and the health care needs of this vulnerable population. Few interventions aimed at educating student nurses about homelessness and changing their attitudes to mitigate bias are based on research, particularly research conducted from the perspective of the homeless, and few explore the impact of civil interactions on health outcomes. The findings of this study may assist nurse educators in developing education interventions to improve students' knowledge of homelessness.

Improving hospital discharge arrangements for people who are homeless: A realist synthesis of the intermediate care literature

This review presents a realist synthesis of "what works and why" in intermediate care for people who are homeless. The overall aim was to update an earlier synthesis of intermediate care by capturing new evidence from a recent UK government funding initiative (the "Homeless Hospital Discharge Fund"). The initiative made resources available to the charitable sector to enable partnership working with the National Health Service (NHS) in order to improve hospital discharge arrangements for people who are homeless. The synthesis adopted the RAMESES guidelines and reporting standards. Electronic searches were carried out for peer-reviewed articles published in English from 2000 to 2016. Local evaluations and the grey literature were also included. The inclusion criteria was that articles and reports should describe "interventions" that encompassed most of the key characteristics of intermediate care as previously defined in the academic literature. Searches yielded 47 articles and reports. Most of these originated in the UK or the USA and fell within the realist quality rating of "thick description". The synthesis involved using this new evidence to interrogate the utility of earlier programme theories. Overall, the results confirmed the importance of (i) collaborative care planning, (ii) reablement and (iii) integrated working as key to effective intermediate care delivery. However, the additional evidence drawn from the field of homelessness highlighted the potential for some theory refinements. First, that "psychologically informed" approaches to relationship building may be necessary to ensure that service users are meaningfully engaged in collaborative care planning and second, that integrated working could be managed differently so that people are not "handed over" at the point at which the intermediate care episode ends. This was theorised as key to ensuring that ongoing care arrangements do not break down and that gains are not lost to the person or the system vis-à-vis the prevention of readmission to hospital.

Illness narratives of people who are homeless

Multiple illnesses are common in all homeless populations. While most previous studies have focused on experiences of mental illness, there is a scarcity of studies about experiences of bodily illness among people who are homeless. This study aimed to explore illness narratives of people who are homeless, and how homelessness as a social context shapes the experience of multiple and/or advancing somatic conditions. The design was a qualitative single-case study, using interpretive description. Data were generated through interviews, with nine participants who were homeless rough sleepers in Stockholm, Sweden, recruited while receiving care in a support home for homeless people with complex care needs. The findings revealed experiences of illness embedded in narratives about falling ill, being ill, and the future. The particularity of these illness narratives and the way that they are shaped by homelessness give rise to several observations: the necessity of a capable body for survival; chaos and profound solitude in illness and self-care management; ambiguous feelings about receiving care, transitioning from independence, and “freedom” in the streets to dependency and being institutionalized; and finally, the absence of hope and desire for recovery or a better future. The narratives are discussed from the perspective of Frank's four types of illness stories (restitution, chaos, quest, and testimony). The findings stress that to provide appropriate care and support to people who are homeless and have multiple and/or advancing somatic conditions, health care professionals need to be informed both about the individual's biography and about the circumstances under which illness and self-care takes place in the streets.

Providing Palliative Care in a Swedish Support Home for People Who Are Homeless

Despite high frequencies of multiple, life-limiting conditions relating to palliative care needs, people who are homeless are one of the most underserved and rarely encountered groups in palliative care settings. Instead, they often die in care places where palliative competence is not available. In this qualitative single-case study, we explored the conditions and practices of palliative care from the perspective of staff at a Swedish support home for homeless people. Interpretive description guided the research process, and data were generated from repeated reflective conversations with staff in groups, individually, and in pairs. The findings disclose a person-centered approach to palliative care, grounded in the understanding of the person's health/illness and health literacy, and how this is related to and determinant on life as a homeless individual. Four patterns shape this approach: building trustful and family-like relationships, re-dignifying the person, re-considering communication about illness and dying, and re-defining flexible and pragmatic care solutions.

A Systematic Review of the Transition from Homelessness to Finding a Home

Homelessness is associated with premature mortality, increased morbidity, and poor quality of life. Transitioning from homelessness to housing is a complex process, particularly for individuals with mental illness. This article presents a systematic review of 26 empirical studies exploring the transition of adults from homelessness to finding a home. Seven qualitative, 14 quantitative, and 5 mixed-method studies were critically appraised and synthesized yielding persistent qualitative themes such as maintaining stability, making adjustments, and a place called home, and quantitative key categories including quality of life, sociodemographics, and housing conditions. More research is needed exploring factors related successful housing placement.

Accessibility patterns and community integration among previously homeless adults: a Geographic Information Systems (GIS) approach

Although a desired rehabilitation goal, research continues to document that community integration significantly lags behind housing stability success rates for people of a variety of ages who used to be homeless. While accessibility to resources is an environmental factor that may promote or impede integration activity, there has been little empirical investigation into the impact of proximity of community features on resource use and integration. Using a Geographic Information Systems (GIS) approach, the current study examines how accessibility or proximity to community features in Boston, United States related to the types of locations used and the size of an individual's "activity space," or spatial presence in the community. Significant findings include an inverse relationship between activity space size and proximity to the number and type of community features in one's immediate area. Specifically, larger activity spaces were associated with neighborhoods with less community features, and smaller activity spaces corresponded with greater availability of resources within one's immediate area. Activity space size also varied, however, based on proximity to different types of resources, namely transportation and health care. Greater community function, or the ability to navigate and use community resources, was associated with better accessibility and feeling part of the community. Finally, proximity to a greater number of individual identified preferred community features was associated with better social integration. The current study suggests the ongoing challenges of successful integration may vary not just based on accessibility to, but relative importance of, specific community features and affinity with one's surroundings. Community integration researchers and housing providers may need to attend to the meaning attached to resources, not just presence or use in the community.

Community reintegration of stroke survivors: the effect of a community navigation intervention

AIM

The overall aim of the proposed study is to examine a newly implemented navigation intervention intended to support stroke survivors' community integration during the first year following hospital discharge in four regions of Ontario, Canada.

BACKGROUND

Stroke is a leading cause of disability worldwide. Stroke survivors living in the community require regular, ongoing follow-up to assess recovery, prevent deterioration and maximize health outcomes. Internationally published evidence, often conducted in large urban centres, suggests that community reintegration services are an important component of the continuum of care for stroke survivors. This evidence, however, often does not address the particular challenges inherent in smaller urban and rural contexts.

DESIGN

The design of this 2-year mixed-method study will use cohort and focused ethnography.

METHODS

The three stages of this study include: (1) collection of quantitative data to profile the health status, support and extent of community reintegration of stroke survivors; (2) collection of qualitative data from stroke survivors and their care partners about community reintegration and navigation; and following triangulation of findings (3) knowledge translation activities. This study was ethically approved by the academic Research Ethics Board and clinical Research Ethics Board (Sudbury, Ontario) and funded by the Ontario Stroke Network (Canada).

DISCUSSION

Results will describe experiences and outcomes of a community navigation intervention. Engagement of multiple stakeholders has the potential to develop a shared understanding of community reintegration and generate evidence informed recommendations for service enhancement at critical points in stroke recovery to support survivor and community well-being.

Measuring community integration using Geographic Information Systems (GIS) and participatory mapping for people who were once homeless

Measures of community integration rely on self-report assessments that often quantify physical or social participation, but fail to capture the individual׳s spatial presence in the community. The current study documents the activity space, or area of daily experiences, of 37 individuals who were once homeless through participatory mapping and Geographic Information Systems (GIS). Contrary to expectations, there was no significant relationship between activity space size and community integration measures, except a negative association with physical integration. Further analysis revealed, however, that continued use of homeless services, geographically spread throughout the city, was associated with larger activity space size, but may be counterproductive to social and psychological integration efforts. Analysis of the types of locations identified revealed high importance given to leisure locations and ongoing involvement with medical and mental health locations. Finally, community integration outcomes did not differ significantly by demographics or housing type, but rather degree of family involvement and feeling like home, factors that may have more potential for change.

Integrating an evidence-based intervention into clinical practice: 'transitional relationship model'

The transitional relationship model (TRM) facilitates the discharge process by providing peer support and hospital staff involvement until a therapeutic relationship has been established with a community care provider. A quasi-experimental, action-oriented research design was employed in which psychiatric wards at six hospital sites implemented the model in three waves. Helpful strategies were identified by each wave of wards for consideration by subsequent wards. Using an ethnographic approach, qualitative data were examined to uncover experiences and perceptions of TRM implementation and to help identify key issues that were supporting or hampering implementation. Specific strategies that facilitate the implementation of TRM include: (1) the use of educational modules for on-ward hospital staff training and peer training; (2) presence of on-site champions; and (3) supportive documentation systems. Issues identified as barriers to implementation included: (1) feeling drowned, swamped and overwhelmed; (2) death by process; (3) team dynamics; and (4) changes in champions. Staged large-scale implementation of the TRM allowed for iterative improvements to the model leading to positive outcomes. This study highlights the need to address work environment issues, particularly interprofessional teams.

The challenges of the homeless haemophilia patient

The current economic hardships within the United States can increase the risk of persons becoming homeless. In 2001, it was estimated that between 0.1% and 2.1% of the population were homeless every night and that 2.3 - 3.5 million persons could become homeless every year [1]. Many issues can increase the risk of homelessness including: home foreclosure, declining work force due to declining wages, low-wage opportunities and less secure jobs, decline in public assistance, lack of affordable housing with limited housing assistance programs, poverty, lack of affordable health care, domestic violence, mental illness, and addiction disorders. Many on the streets may suffer from mental illness, developmental disabilities, and or chronic physical illness [6]. Given these issues, the Hemophilia Treatment Center (HTC) can expect to experience the issue of homelessness within their own population of persons with hemophilia. Currently, there are no studies that address the issue of the person with hemophilia who may become homeless. This presents unique challenges that this population may encounter to survive in addition to managing bleeding issues related to the diagnosis of hemophilia. This article will review the issues related to homelessness in the general population. Two case studies of persons with hemophilia who became homeless will be discussed outlining the strategies utilized to assist the patient during this crisis.

Preventing homelessness after discharge from psychiatric wards: perspectives of consumers and staff

After spending time in the hospital, psychiatric clients are often discharged to homeless shelters or the streets, which can place a burden on health care systems. This study examined the effects of an intervention in which psychiatric clients from acute (n = 219) and tertiary (n = 32) sites were provided with predischarge assistance in securing housing. A program evaluation design was used to examine the effectiveness of the intervention. Qualitative data were available through interviews, focus groups, and monthly meetings. The results highlight several benefits of the intervention and show that homelessness can be reduced by connecting housing support, income support, and psychiatric care.

Exploring transitions within a project-based Housing First setting: qualitative evaluation and practice implications

The Housing First (HF) approach is a model of housing that entails the provision of immediate, permanent, low-barrier, supportive housing to chronically homeless individuals either in separate apartments within a larger community (known as scattered-site HF) or in a single building (known as project-based HF). One recent innovation is the application of project-based HF with chronically homeless individuals with alcohol problems. Although initial studies have shown its effectiveness, there is currently no research on residents' and staff 's experiences living and working in a project-based HF program. The purpose of this article was to document these experiences and highlight strengths and challenges of project-based HF programs. Using data collected from naturalistic observations, agency documentation, one-on-one resident interviews, and a staff focus group, we delineated transitional periods, including moving into project-based HF, community-building, managing day-to-day, and transitions from project-based HF. Findings are interpreted to help health care policymakers and providers envision the role of project-based HF in comprehensive public health efforts and to integrate lessons learned into their own clinical practice.