From Their Perspective: The Connection between Life Stressors and Health Care Service Use Patterns of Homeless Frequent Users of the Emergency Department

Extreme Risk Protection Orders in Washington State: Understanding the Role of Health Professionals

Objective

Extreme Risk Protection Orders (ERPO) allow a petitioner to file a civil order to temporarily restrict access to firearms among individuals ("respondents") deemed to be at extreme risk of harming themselves, others, or both. Although unable to file ERPOs for their clients in most states, health professionals may play a pivotal role in the ERPO process by recommending an eligible petitioner initiate the process. We describe the process of filing an ERPO when a healthcare, mental health, or social service professional contacted an ERPO petitioner.

Method

Court documents of ERPOs involving health professionals in Washington State between December 8th, 2016 and May 10th, 2019 were qualitatively analyzed (n=24). We constructed pen portraits from the documents and analyzed them using an inductive qualitative thematic approach.

Results

Themes included factors influencing the process by which each professional evaluated respondent behaviors, factors considered during assessment, factors influencing interpretation of respondent behaviors and subsequent provider response during a crisis. These influenced the outcome of the crisis event that led to ERPO filing.

Conclusions

Each professional group differed in their approach to risk assessment of respondent behaviors. Strategies to better coordinate and align approaches may improve the ERPO process.

Supporting Older Homeless Persons' Positive Relocations to Long-Term Care: Service Provider Views

BACKGROUND AND OBJECTIVES

This study sought to explore the challenges and opportunities associated with supporting older homeless persons' relocations to long-term care (LTC) from the perspective of service providers. It aims to inform how to improve relocation processes for this vulnerable and growing subpopulation of older persons.

RESEARCH DESIGN AND METHODS

This cross-sectional qualitative study employed semistructured face-to-face interviews with service providers from two Health and Social Service Centres in Montreal, Quebec. All interviews were audio-recorded, transcribed verbatim, and thematically analyzed in five stages.

RESULTS

A total of eight service providers reported on their experiences supporting over 40 relocations of older homeless persons (50+) in the last year. According to participants, older homeless persons' trajectories into LTC typically included a series of neglected medical issues followed by hospitalization and eventual relocation to LTC. Systemic barriers such as limited-time for proper planning, insufficient housing options for persons with minor functional limitations, disregard for preferred geographic location, multiple moves, and staff prejudices worked together to expedite premature relocation and challenge relocation processes.

DISCUSSION AND IMPLICATIONS

Older homeless persons appear to be at heightened risk of premature and challenging relocation processes. Expanding housing stock for persons with functional limitations, strengthening intersectoral collaborations, providing education and training to staff, and ensuring flexibility around rules and regulations in receiving LTC homes would both improve access to aging in place for this marginalized group of older persons and ensure conditions are in place to support positive relocations to LTC for those who require it.

Supporting Primary Care Access and Use among Homeless Persons

With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity.

The Sustainability of Public Social Services: A Qualitative Study

The 2008 global economic crisis heightened social inequality and drastically reduced equal opportunities for many people. It had negative consequences for social regulation in many European countries, which have dismantled their public social policies. The objective of the study was to describe social workers’ perceptions of their lived experiences in different areas of the public social services system. A qualitative study was developed, based on a hermeneutic approach. Six in-depth interviews and two focus groups were conducted with 20 social workers employed by community social services and the Andalusian public health service (Spain). The professionals agreed that the public social services system has been eroded, that the lack of resources has consequences for workers and the general public alike, and that the public authorities and the administration are responsible for this situation. Social services have become distributors of scarce resources rather than a social protection system that empowers and accompanies the most vulnerable. The system must provide the necessary resources and structures so that they can escape the situation of poverty, exclusion and social injustice.

Comparing neighborhood-based indices of socioeconomic risk factors and potentially preventable emergency department utilization

BACKGROUND

Neighborhood stress score (NSS) and area deprivation index (ADI) are two neighborhood-based composite measures used to quantify an individual's socioeconomic risk based on home location. In this analysis, we compare the relationships between an individual's socioeconomic risk, based on each of these measures, and potentially preventable acute care utilization.

METHODS

Using emergency department (ED) visit data from two academic medical centers in Boston, Massachusetts, we conducted adjusted Poisson regressions of ADI decile and NSS decile with counts of low acuity ED visits, admissions for ambulatory care sensitive conditions (ACSCs), and patients with high frequency ED utilization at the census block group (CBG) level within the greater Boston area.

RESULTS

Both NSS and ADI decile were associated with elevated rates of utilization, although the associated incidence rate ratios (IRRs) for NSS were higher than those for ADI across all three measures. NSS decile was associated with IRRs of 1.11 [95% CI: 1.10-1.12], 1.16 [1.14-1.17], and 1.22 [1.19-1.25] for ACSC admissions, low acuity ED visits, and patients with high frequency ED utilization, respectively; compared with 1.04 [1.04-1.05], 1.11 [1.10-1.11], and 1.10 [1.08-1.12] for ADI decile.

CONCLUSION

ADI and NSS both represent effective tools to assess the potential impact of geographically-linked socioeconomic drivers of health on potentially preventable acute care utilization. NSS decile was associated with a greater effect size for each measure of utilization suggesting that this may be a stronger predictor, however, additional research is necessary to evaluate these findings in other contexts.

Variables associated with low, moderate and high emergency department use among patients with substance-related disorders

AIMS

This study identified factors associated with frequency of emergency department (ED) use for medical reasons among patients with substance-related disorders (SRD) in Quebec (Canada) for 2014-15.

METHODS

Participants (n = 4731) were categorized as: 1) low (1 visit/year), 2) moderate (2 visits/year), and 3) high (3+ visits/year) ED users. Independent variables included predisposing, enabling and needs factors based on the Andersen Behavioral Model. Multinomial logistic regression identified associated variables.

RESULTS

Factors positively associated with moderate and high ED use included adjustment disorders, suicidal behavior, alcohol-induced disorders, less urgent to non-urgent illness acuity, referral to local health community services centers (LHCSC) at discharge, and living in a materially deprived area. Factors positively associated with high ED use only included anxiety disorders, alcohol use disorders, drug use disorders, chronic physical illness, subacute problems, prior ED use for MD and/or SRD, prior LHCSC medical interventions, physician consultation within one month after discharge, living in very deprived or middle-class areas, and, negatively, being hospitalized for medical reasons in second ED visit. Moderate ED use only was negatively associated with alcohol intoxication and being referred to a GP at ED discharge.

CONCLUSIONS

Compared to low ED users, most high users with SRD were men presenting more complex and severe conditions. They visited ED mainly for subacute or non-urgent problems. Compared to low ED users, most moderate users had alcohol-induced disorders, less alcohol intoxication, and acute common MD. They visited ED mainly for non-urgent care. Diverse strategies should be implemented to reduce ED visits, targeting each group.

Experiences of Care in the Emergency Department Among a Sample of Homeless Male Veterans: A Qualitative Study

INTRODUCTION

Homeless populations are historically high users of the emergency department for low-acuity issues that could be treated in more appropriate settings such as primary care. Veterans make up 11% of the homeless adult population and are often seen in community and Veterans Affairs Medical Center (VAMC) emergency departments. The purpose of this study was to describe the experiences of a sample of homeless male veterans as they attempt to access health care in the emergency department.

METHODS

Grounded theory methodology provided the overarching framework for this research project. Structured interviews were conducted with 34 male homeless veterans, with 25 discussing their ED care. Veterans were recruited and interviewed from one VAMC emergency department, an all-male emergency shelter, and 1 soup kitchen. Text units about ED use were extracted and compared from 25 recorded transcripts to identify categories.

RESULTS

Three categories defined ED experiences: "no other option," "lack of voice," and "feeling valued."

DISCUSSION

The sample of homeless veterans in this study provided first-person knowledge about their experiences receiving care in emergency departments. These results are consistent with previous research indicating that homeless populations are high users of ED care; however, they often feel undervalued and lack of empathy from health providers. Emergency nurses are an integral part of the ED health care delivery system for the homeless, providing advocacy and much needed education about health problems and alternatives to ED care. The insight obtained about the lives and experiences of veterans in the ED is valuable to the practice of emergency nurses.