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Plage S, Baker K, Parsell C, Stambe R, Kuskoff E, Mansuri A. Staying safe, feeling welcome, being seen: How spatio-temporal configurations affect relations of care at an inclusive health and wellness centre. Health Expect 2023; 26:2620-2629. [PMID: 37656503 PMCID: PMC10632618 DOI: 10.1111/hex.13858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND People experiencing homelessness also experience poorer health and frequently attend acute care settings when primary health care would be better equipped to meet their needs. Existing scholarship identifies a complex mix of individual and structural-level factors affecting primary health care engagement driving this pattern of health services utilisation. We build on this existing knowledge, by bringing the spatio-temporal configurations of primary health care into focus. Specifically, we interrogate how space and time inflect situated practices and relations of care. METHODS This study took an ethnographic approach and was conducted 2021-2022 at an inclusive health and wellness centre ("the Centre") in Southeast Queensland, Australia. The data consists of 46 interviews with 48 people with lived experience of homelessness, including participants who use the services offered at the Centre (n = 26) and participants who do not (n = 19). We also interviewed 20 clinical and non-clinical service providers affiliated with the Centre and observed how service delivery took place. Interviews and observations were complemented by visual data, including participant-produced photography. All data were analysed employing a narrative framework. RESULTS We present three interrelated themes demonstrating how space and time affect care, that is 'staying safe', 'feeling welcome' and 'being seen'. 'Staying safe' captures the perceptions and practices around safety, which sit in tension with making service users feel welcome. 'Feeling welcome' attends to the sense of being invited to use services free of judgment. 'Being seen' depicts capacities to see a health care provider as well as being understood in one's lived experience. CONCLUSION Spatio-temporal configurations, such as attendance policies, consultation modalities and time allocated to care encounters afford differential opportunities to nurture reciprocal relations. We conclude that flexible service configurations can leverage a relational model of care. PATIENT OR PUBLIC CONTRIBUTION Service providers were consulted during the design stage of the project and had opportunities to inform data collection instruments. Two service providers contributed to the manuscript as co-authors. People with lived experience of homelessness who use the services at the inclusive health centre contributed as research participants and provided input into the dissemination of findings. The photography they produced has been featured in an in-person exhibition, to which some have contributed as consultants or curators. It is hoped that their insights into experiences of welcomeness, safety and being seen will inform flexible and relational primary health care design, delivery, and evaluation to better cater for people experiencing housing instability and poverty.
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Affiliation(s)
- Stefanie Plage
- ARC Centre of Excellence for Children and Families over the Life CourseIndooroopillyAustralia
| | - Kirsten Baker
- Australian Research Centre in Complementary and Integrative MedicineThe University of Technology SydneyBroadwayAustralia
- Inclusive Health and Wellness HubSouth BrisbaneAustralia
| | - Cameron Parsell
- ARC Centre of Excellence for Children and Families over the Life CourseIndooroopillyAustralia
| | - Rose‐Marie Stambe
- ARC Centre of Excellence for Children and Families over the Life CourseIndooroopillyAustralia
| | - Ella Kuskoff
- ARC Centre of Excellence for Children and Families over the Life CourseIndooroopillyAustralia
| | - Arif Mansuri
- Inclusive Health and Wellness HubSouth BrisbaneAustralia
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Yore M, Fockele CE, Duber HC, Doran KM, Cooper RJ, Lin MP, Campbell S, Eswaran V, Chang B, Hong H, Gbenedio K, Stanford KA, Gavin N. 2021 SAEM Consensus Conference Proceedings: Research Priorities for Implementing Emergency Department Screening for Social Risks and Needs. West J Emerg Med 2023; 24:302-311. [PMID: 36976611 PMCID: PMC10047739 DOI: 10.5811/westjem.2022.10.57368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 10/06/2022] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION Despite literature on a variety of social risks and needs screening interventions in emergency department (ED) settings, there is no universally accepted or evidence-based process for conducting such interventions. Many factors hamper or promote implementation of social risks and needs screening in the ED, but the relative impact of these factors and how best to mitigate/leverage them is unknown. METHODS Drawing on an extensive literature review, expert assessment, and feedback from participants in the 2021 Society for Academic Emergency Medicine Consensus Conference through moderated discussions and follow-up surveys, we identified research gaps and rated research priorities for implementing screening for social risks and needs in the ED. We identified three main knowledge gaps: 1) screening implementation mechanics; 2) outreach and engagement with communities; and 3) addressing barriers and leveraging facilitators to screening. Within these gaps, we identified 12 high-priority research questions as well as research methods for future studies. RESULTS Consensus Conference participants broadly agreed that social risks and needs screening is generally acceptable to patients and clinicians and feasible in an ED setting. Our literature review and conference discussion identified several research gaps in the specific mechanics of screening implementation, including screening and referral team composition, workflow, and use of technology. Discussions also highlighted a need for more collaboration with stakeholders in screening design and implementation. Additionally, discussions identified the need for studies using adaptive designs or hybrid effectiveness-implementation models to test multiple strategies for implementation and sustainability. CONCLUSION Through a robust consensus process we developed an actionable research agenda for implementing social risks and needs screening in EDs. Future work in this area should use implementation science frameworks and research best practices to further develop and refine ED screening for social risks and needs and to address barriers as well as leverage facilitators to such screening.
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Affiliation(s)
- Mackensie Yore
- VA Los Angeles and UCLA National Clinician Scholars Program, VA Greater Los Angeles Healthcare System HSR&D Center of Innovation, Los Angeles, California
| | | | - Herbert C Duber
- University of Washington, Department of Emergency Medicine, Seattle, Washington
| | - Kelly M Doran
- NYU Grossman School of Medicine, Departments of Emergency Medicine and Population Health, New York, New York
| | - Richelle J Cooper
- UCLA David Geffen School of Medicine, UCLA Department of Emergency Medicine, Los Angeles, California
| | - Michelle P Lin
- Stanford University, Department of Emergency Medicine, Stanford, California
| | | | - Vidya Eswaran
- Baylor College of Medicine, Department of Emergency Medicine and Section of Health Services Research, Department of Medicine, Houston, Texas
| | - Betty Chang
- Columbia University, Department of Emergency Medicine, New York, New York
| | - Haeyeon Hong
- Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Kessiena Gbenedio
- Columbia University, Department of Emergency Medicine, New York, New York
| | | | - Nicholas Gavin
- Mount Sinai Icahn School of Medicine, Department of Emergency Medicine, New York, New York
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Tsai J, Havlik J, Howell BA, Johnson E, Rosenthal D. Primary Care for Veterans Experiencing Homelessness: a Narrative Review of the Homeless Patient Aligned Care Team (HPACT) Model. J Gen Intern Med 2023; 38:765-783. [PMID: 36443628 PMCID: PMC9971390 DOI: 10.1007/s11606-022-07970-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/16/2022] [Indexed: 11/29/2022]
Abstract
In 2011, the U.S. Department of Veterans Health (VA) implemented a homeless-tailored primary care medical home model called the Homeless Patient Aligned Care Teams (HPACTs). The impact of HPACTs on health and healthcare outcomes of veterans experiencing homelessness has not been adequately synthesized. This narrative review summarized peer-reviewed studies published in databases Ovid MEDLINE, Ovid EMBASE, and APA PsycInfo from 1946 to February 2022. Only original research studies that reported outcomes of the HPACT model were included in the review. Of 575 studies that were initially identified and screened, 26 studies met inclusion criteria and were included in this review. Included studies were categorized into studies that described the following: (1) early HPACT pilot implementation; (2) HPACT's association with service quality and utilization; and (3) specialized HPACT programs. Together, studies in this review suggest HPACT is associated with reductions in emergency department utilization and improvements in primary care utilization, engagement, and positive patient experiences; however, the methodological rigor of the included studies was low, and thus, these findings should only be considered preliminary. There is a need for randomized controlled trials assessing the impact of the PACT model on key outcomes of interest, as well as to determine whether the model is a viable way to manage healthcare for persons experiencing homelessness outside of the VA system.
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Affiliation(s)
- Jack Tsai
- Office of Homeless Programs, U.S. Department of Veterans Affairs, Washington D.C., USA.
- University of Texas Health Science Center at Houston, School of Public Health, 1200 Pressler St, Houston, TX, 77030, USA.
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.
| | - John Havlik
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Benjamin A Howell
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Erin Johnson
- Office of Homeless Programs, U.S. Department of Veterans Affairs, Washington D.C., USA
| | - David Rosenthal
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- 4Catalyzer Inc., CT, Guilford, USA
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Luchenski SA, Dawes J, Aldridge RW, Stevenson F, Tariq S, Hewett N, Hayward AC. Hospital-based preventative interventions for people experiencing homelessness in high-income countries: A systematic review. EClinicalMedicine 2022; 54:101657. [PMID: 36311895 PMCID: PMC9597099 DOI: 10.1016/j.eclinm.2022.101657] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 08/15/2022] [Accepted: 08/29/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND People experiencing homelessness have significant unmet needs and high rates of unplanned care. We aimed to describe preventative interventions, defined in their broadest sense, for people experiencing homelessness in a hospital context. Secondary aims included mapping outcomes and assessing intervention effectiveness. METHODS We searched online databases (MEDLINE, Embase, PsycINFO, HMIC, CINAHL, Web of Science, Cochrane Library) from 1999-2019 and conducted backward and forward citation searches to 31 December 2020 (PROSPERO CRD42019154036). We included quantitative studies in emergency and inpatient settings measuring health or social outcomes for adults experiencing homelessness in high income countries. We assessed rigour using the "Quality Assessment Tool for Quantitative Studies" and summarised findings using descriptive quantitative methods, a binomial test, a Harvest Plot, and narrative synthesis. We used PRISMA and SWiM reporting guidelines. FINDINGS Twenty-eight studies identified eight intervention types: care coordination (n=18); advocacy, support, and outreach (n=13); social welfare assistance (n=13); discharge planning (n=12); homelessness identification (n=6); psychological therapy and treatment (n=6); infectious disease prevention (n=5); and screening, treatment, and referrals (n=5). The evidence strength was weak (n=16) to moderate (n=10), with two high quality randomised controlled trials. We identified six outcome categories with potential benefits observed for psychosocial outcomes, including housing (11/13 studies, 95%CI=54.6-98.1%, p=0.023), healthcare use (14/17, 56.6-96.2%, p=0.013), and healthcare costs (8/8, 63.1-100%, p=0.008). Benefits were less likely for health outcomes (4/5, 28.3-99.5%, p=0.375), integration with onward care (2/4, 6.8-93.2%, p=1.000), and feasibility/acceptability (5/6, 35.9-99.6%, p=0.219), but confidence intervals were very wide. We observed no harms. Most studies showing potential benefits were multi-component interventions. INTERPRETATION Hospital-based preventative interventions for people experiencing homelessness are potentially beneficial, but more rigorous research is needed. In the context of high needs and extreme inequities, policymakers and healthcare providers may consider implementing multi-component preventative interventions. FUNDING SL is supported by an NIHR Clinical Doctoral Research Fellowship (ICA-CDRF-2016-02-042). JD is supported by an NIHR School of Public Health Research Pre-doctoral Fellowship (NU-004252). RWA is supported by a Wellcome Clinical Research Career Development Fellowship (206602).
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Affiliation(s)
- Serena A. Luchenski
- Collaborative Centre for Inclusion Health, Institute of Epidemiology and Healthcare, University College London, 1-19 Torrington Place, London WC1E 7HT, United Kingdom
- Corresponding author.
| | - Joanna Dawes
- Collaborative Centre for Inclusion Health, Institute of Epidemiology and Healthcare, University College London, 1-19 Torrington Place, London WC1E 7HT, United Kingdom
| | - Robert W. Aldridge
- Centre for Public Health Data Science, Institute for Health Informatics, University College London, 255 Euston Road, London NW1 2DA, United Kingdom
| | - Fiona Stevenson
- Department of Primary Care and Population Health, Institute of Epidemiology and Healthcare, University College London, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, United Kingdom
| | - Shema Tariq
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, Mortimer Market Centre, off Capper Street, London WC1E 6JB, United Kingdom
| | - Nigel Hewett
- Pathway, 4th Floor, East, 250 Euston Rd, London NW1 2PG, United Kingdom
| | - Andrew C. Hayward
- Collaborative Centre for Inclusion Health, Institute of Epidemiology and Healthcare, University College London, 1-19 Torrington Place, London WC1E 7HT, United Kingdom
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Fazio D, Zuiderveen S, Guyet D, Reid A, Lalane M, McCormack RP, Wall SP, Shelley D, Mijanovich T, Shinn M, Doran KM. ED-Home: Pilot feasibility study of a targeted homelessness prevention intervention for emergency department patients with drug or unhealthy alcohol use. Acad Emerg Med 2022; 29:1453-1465. [PMID: 36268815 PMCID: PMC10440066 DOI: 10.1111/acem.14610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/10/2022] [Accepted: 10/15/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Housing insecurity is prevalent among emergency department (ED) patients. Despite a surge of interest in screening for patients' social needs including housing insecurity, little research has examined ED social needs interventions. We worked together with government and community partners to develop and pilot test a homelessness prevention intervention targeted to ED patients with drug or unhealthy alcohol use. METHODS We approached randomly sampled patients at an urban public hospital ED, May to August 2019. Adult patients were eligible if they were medically stable, not incarcerated, spoke English, had unhealthy alcohol or any drug use, and were not currently homeless but screened positive for risk of future homelessness using a previously developed risk screening tool. Participants received a three-part intervention: (1) brief counseling and referral to treatment for substance use delivered through a preexisting ED program; (2) referral to Homebase, an evidence-based community homelessness prevention program; and (3) up to three troubleshooting phone calls by study staff. Participants completed surveys at baseline and 6 months. RESULTS Of 2183 patients screened, 51 were eligible and 40 (78.4%) participated; one later withdrew, leaving 39 participants. Participants were diverse in age, gender, race, and ethnicity. Of the 32 participants reached at 6 months, most said it was very or extremely helpful to talk to someone about their housing situation (n = 23, 71.9%) at the baseline ED visit. Thirteen (40.6%) said their housing situation had improved in the past 6 months and 16 (50.0%) said it had not changed. Twenty participants (62.5%) had made contact with a Homebase office. Participants shared ideas of how to improve the intervention. CONCLUSIONS This pilot intervention was feasible and well received by participants though it required a large amount of screening to identify potentially eligible patients. Our findings will inform a larger future trial and may be informative for others seeking to develop similar interventions.
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Affiliation(s)
- Daniela Fazio
- Department of Emergency Medicine, NYU School of Medicine, New York, New York, USA
| | - Sara Zuiderveen
- Homelessness Prevention Administration, NYC Human Resources Administration, New York, New York, USA
| | - Dana Guyet
- Homelessness Prevention Administration, NYC Human Resources Administration, New York, New York, USA
| | - Andrea Reid
- Homelessness Prevention Administration, NYC Human Resources Administration, New York, New York, USA
| | - Monique Lalane
- Bellevue Hospital, NYC Health + Hospitals, New York, New York, USA
| | - Ryan P McCormack
- Department of Emergency Medicine, NYU School of Medicine, New York, New York, USA
| | - Stephen P Wall
- Department of Emergency Medicine, NYU School of Medicine, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
| | - Donna Shelley
- Department of Public Health Policy and Management, NYU School of Global Public Health, New York, New York, USA
- Global Center for Implementation Science and Practice, NYU School of Global Public Health, New York, New York, USA
| | - Tod Mijanovich
- Department of Applied Statistics, Social Sciences, and Humanities, NYU Steinhardt School, New York, New York, USA
| | - Marybeth Shinn
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, Tennessee, USA
| | - Kelly M Doran
- Department of Emergency Medicine, NYU School of Medicine, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
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Varley AL, Hoge A, Riggs KR, deRussy A, Jones AL, Austin EL, Gabrielian S, Gelberg L, Gordon AJ, Blosnich JR, Montgomery AE, Kertesz SG. What do Veterans with homeless experience want us to know that we are not asking? A qualitative content analysis of comments from a national survey of healthcare experience. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e5027-e5037. [PMID: 35866310 PMCID: PMC9942008 DOI: 10.1111/hsc.13918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 06/15/2022] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
Surveys of people who experience homelessness can portray their life and healthcare experiences with a level of statistical precision; however, few have explored how the very same surveys can deliver qualitative insights as well. In responding to surveys, people experiencing homelessness can use the margins to highlight health and social concerns that investigators failed to anticipate that standard question batteries miss. This study describes the unprompted comments of a large national survey of Veterans with homeless experiences. The Primary Care Quality-Homeless Services Tailoring (PCQ-HOST) survey presented 85 close-ended items to solicit social and psychological experiences, health conditions, and patient ratings of primary care. Amongst 5377 Veterans responding to the paper survey, 657 (12%) offered 1933 unprompted comments across nearly all domains queried. Using a team-based content analysis approach, we coded and organised survey comments by survey domain, and identified emergent themes. Respondents used comments for many purposes. They noted when questions called for more nuanced responses than those allowed, especially 'sometimes' or 'not applicable' on sensitive questions, such as substance use, where recovery status was not queried. On such matters, the options of 'no' and 'yes' failed to capture important contextual and historical information that mattered to respondents, such as being in recovery. Respondents also elaborated on negative and positive care experiences, often naming specific clinics or clinicians. This study highlights the degree to which members of vulnerable populations, who participate in survey research, want researchers to know the reasons behind their responses and topics (like chronic pain and substance use disorders) that could benefit from open-ended response options. Understanding patient perspectives can help improve care. Quantitative data from surveys can provide statistical precision but may miss key patient perspectives. The content that patients write into survey margins can highlight shortfalls of a survey and point towards future areas of inquiry. Veterans with homeless experience want to provide additional detail about their lives and care experiences in ways that transcend the boundaries of close-ended survey questions. Questions on substance use proved especially likely to draw comments that went beyond the permitted response options, often to declare that the respondent was in recovery. Respondents frequently clarified aspects of their care experiences related to pain, pain care, transportation and experiences of homelessness.
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Affiliation(s)
- Allyson L Varley
- Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
| | - April Hoge
- Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
| | - Kevin R Riggs
- Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Aerin deRussy
- Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
| | - Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Erika L Austin
- University of Alabama at Birmingham School of Public Health, Birmingham, Alabama, USA
| | - Sonya Gabrielian
- VA Greater Los Angeles, Los Angeles, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Lillian Gelberg
- VA Greater Los Angeles, Los Angeles, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Ann Elizabeth Montgomery
- Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
- University of Alabama at Birmingham School of Public Health, Birmingham, Alabama, USA
| | - Stefan G Kertesz
- Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Al-Dulaimi R, Duong PA, Chan BY, Fuller MJ, Ross AB, Dunn DP. Revisiting racial disparities in ED CT utilization during the Affordable Care Act era: 2009-2018 data from the NHAMCS. Emerg Radiol 2021; 29:125-132. [PMID: 34713355 DOI: 10.1007/s10140-021-01991-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/13/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the trends in CT utilization in the emergency department (ED) for different racial and ethnic groups, factors that may affect utilization, and the effects of increased insurance coverage since passage of the Affordable Care Act in 2010. MATERIALS AND METHODS Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 2009-2018 were used for the analysis. The NHAMCS is a cross-sectional survey which has random and systematical samples of more than 200,000 visits to over 250 hospital EDs in the USA. Patient demographic characteristics, source of payment/insurance, clinical presentation, and disposition from the ED were recorded. Descriptive statistics and multivariate logistic regression were performed. RESULTS Between 2009 and 2018, the rate of uninsured patients in the ED decreased from 18.1% to as low as 9.9%, but this was not associated with a decrease in the disparity in CT utilization between non-Hispanic Black and non-Hispanic White patients. CT use rate increased 38% over the study period. Factors strongly associated with CT utilization include age, source of payment, triage category, disposition from the ED, and residence. After controlling for these factors, non-Hispanic White patients were 21% more likely to undergo CT than non-Hispanic Black patients, though no disparity was seen for Hispanic or Asian/other groups. CONCLUSION Despite increased insurance coverage over the sample period, racial disparities between non-Hispanic Black and non-Hispanic White patients persist in CT utilization, though no disparity was seen for Hispanic or Asian/other patients. The source of this disparity remains unclear and is likely multifactorial.
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Affiliation(s)
- Ragheed Al-Dulaimi
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA
| | - Phuong-Anh Duong
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA
| | - Brian Y Chan
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA
| | - Matthew J Fuller
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Andrew B Ross
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Dell P Dunn
- Department of Radiology & Imaging Sciences, University of Utah School of Medicine, 30 North 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA.
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Crone B, Metraux S, Sbrocco T. Health Service Access Among Homeless Veterans: Health Access Challenges Faced by Homeless African American Veterans. J Racial Ethn Health Disparities 2021; 9:1828-1844. [PMID: 34402040 PMCID: PMC8367031 DOI: 10.1007/s40615-021-01119-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 11/28/2022]
Abstract
Veteran homelessness is a public health crisis, especially among the disproportionate number of minority veterans in the homeless veteran population. African American homeless veterans in particular face unique challenges accessing appropriate health care services to meet their medical needs. Their needs are often underrepresented in the literature on veteran homelessness. Drawing together over 80 studies and government reports from the last two decades, this review provides a timely synopsis of homeless veterans' health care access, with a particular focus on the barriers faced by African American veterans. This review employs Penchansky and Thomas' Access Model to frame health access barriers faced by homeless veterans, dialing in on what is known about the experience of African American veterans, within the five dimensions of access: Availability, Accessibility, Accommodation, Affordability, and Acceptability. Actionable guidance and targeted interventions to address health access barriers for all veterans are delineated with a focus on the need to gather further data for African American homeless veterans and to consider tailoring interventions for this important and underserved group.
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Affiliation(s)
- Baylee Crone
- Uniformed Service University of the Health Sciences, Bethesda, MD, USA.
| | | | - Tracy Sbrocco
- Uniformed Service University of the Health Sciences, Bethesda, MD, USA
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9
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Gilmer C, Buccieri K. Homeless Patients Associate Clinician Bias With Suboptimal Care for Mental Illness, Addictions, and Chronic Pain. J Prim Care Community Health 2021; 11:2150132720910289. [PMID: 32133906 PMCID: PMC7059226 DOI: 10.1177/2150132720910289] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To determine how accessible health care services are for people who are experiencing homelessness and to understand from their perspectives what impact clinician bias has on the treatment they receive. Methods: Narrative interviews were conducted with 53 homeless/vulnerably housed individuals in Ontario, Canada. Visit history records were subsequently reviewed at 2 local hospitals, for 52 of the interview participants. Results: Of the 53 participants only 28% had a primary care provider in town, an additional 40% had a provider in another town, and 32% had no access to a primary care provider at all. A subset of the individuals were frequent emergency department users, with 15% accounting for 75% of the identified hospital visits, primarily seeking treatment for mental illness, pain, and addictions. When seeking primary care for these 3 issues participants felt medication was overprescribed. Conversely, in emergency care settings participants felt prejudged by clinicians as being drug-seekers. Participants believed they received poor quality care or were denied care for mental illness, chronic pain, and addictions when clinicians were aware of their housing status. Conclusion: Mental illness, chronic pain, and addictions issues were believed by participants to be poorly treated due to clinician bias at the primary, emergency, and acute care levels. Increased access to primary care in the community could better serve this marginalized population and decrease emergency department visits but must be implemented in a way that respects the rights and dignity of this patient population.
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Affiliation(s)
| | - Kristy Buccieri
- Trent University, Peterborough, Ontario,
Canada
- Kristy Buccieri, Department of Sociology,
Trent University, 1600 West Bank Drive, Peterborough, Ontario K9L 0G2, Canada.
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10
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Holmes CT, Holmes KA, MacDonald A, Lonergan FR, Hunt JJ, Shaikh S, Cheeti R, D'Etienne JP, Zenarosa NR, Wang H. Dedicated homeless clinics reduce inappropriate emergency department utilization. J Am Coll Emerg Physicians Open 2020; 1:829-836. [PMID: 33145527 PMCID: PMC7593501 DOI: 10.1002/emp2.12054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/28/2020] [Accepted: 03/04/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The homeless patient population is known to have a high occurrence of inappropriate emergency department (ED) utilization. The study hospital initiated a dedicated homeless clinic targeting patients experiencing homelessness with a combination of special features. We aim to determine whether this mode of care can reduce inappropriate ED utilization among homeless patients. METHODS We conducted a retrospective observational study from July 1, 2017 to Dec 31, 2017. The study enrolled all homeless patients who visited any hospital regular clinic, dedicated homeless clinic, and ED at least once during the study period. ED homeless patients were divided into four groups (A: no clinic visits; B: those who only visited hospital regular clinic; C: those who only visited dedicated homeless clinic; and D: those who visited both hospital regular clinic and dedicated homeless clinic). The New York University algorithm was used to determine appropriate ED utilization. We compared inappropriate ED utilization among patients from these groups. Multivariate logistic regression was used to determine the risks of different clinical visits in association with inappropriate ED utilization. RESULTS A total of 16,323 clinic and 8511 ED visits occurred among 5022 unique homeless patients, in which 2450 unique patients were seen in hospital regular clinic, 784 patients in dedicated homeless clinic, 688 patients in both hospital regular clinic and dedicated homeless clinic, and 1110 patients with no clinic visits. Twenty-nine percent (230/784) of patients from dedicated homeless clinic utilized the ED, among which 21% (175/844) of their ED visits were considered inappropriate. In contrast, 40% of patients from hospital regular clinic utilized the ED, among which 29% were inappropriate (P < 0.001). The adjusted odds ratio (OR) was 0.61 (95% confidence interval [CI] = 0.50-0.74, P < 0.001) on dedicated homeless clinic predicting inappropriate ED visits in multivariate logistic regression. CONCLUSION Implementing a dedicated homeless clinic with these features can reduce ED inappropriate utilization among patients experiencing homelessness.
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Affiliation(s)
- Chad T. Holmes
- Department of Emergency MedicineJohn Peter Smith Health NetworkFort WorthTexas
- Integrative Emergency ServicesDallasTexas
| | - Katherine A. Holmes
- Department of Emergency MedicineJohn Peter Smith Health NetworkFort WorthTexas
- Integrative Emergency ServicesDallasTexas
| | - Andrew MacDonald
- Department of Emergency MedicineJohn Peter Smith Health NetworkFort WorthTexas
| | - Frank R. Lonergan
- Department of Family MedicineJohn Peter Smith Health NetworkFort WorthTexas
| | - Joel J. Hunt
- Department of Family MedicineJohn Peter Smith Health NetworkFort WorthTexas
| | - Sajid Shaikh
- Department of Information TechnologyJohn Peter Smith Health NetworkFort WorthTexas
| | - Radhika Cheeti
- Department of Information TechnologyJohn Peter Smith Health NetworkFort WorthTexas
| | - James P. D'Etienne
- Department of Emergency MedicineJohn Peter Smith Health NetworkFort WorthTexas
- Integrative Emergency ServicesDallasTexas
| | - Nestor R. Zenarosa
- Department of Emergency MedicineJohn Peter Smith Health NetworkFort WorthTexas
- Integrative Emergency ServicesDallasTexas
| | - Hao Wang
- Department of Emergency MedicineJohn Peter Smith Health NetworkFort WorthTexas
- Integrative Emergency ServicesDallasTexas
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Byhoff E, De Marchis EH, Gottlieb L, Halperin-Goldstein S, Nokes K, LeClair AM. Screening for Immigration-Related Health Concerns in a Federally Qualified Health Center Serving a Diverse Latinx Community: A Mixed Methods Study. J Immigr Minor Health 2020; 22:988-995. [PMID: 32277341 PMCID: PMC7442677 DOI: 10.1007/s10903-020-01005-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Immigration-related concerns can impact health and are an important consideration while caring for a multinational Latinx immigrant community. Patients and caregivers waiting for a non-urgent clinic appointment were randomly screened with one of two social risk screening tools. One tool included a question about "any health or stability concerns related to immigration status." The other tool did not include an immigration health question. Immediately following, respondents were invited to participate in a semi-structured interview regarding their social risk screening experience. 201 screens were completed, and 20 patients agreed to an interview. There were no significant sociodemographic differences between groups. Of those screened for immigration, 11% reported a concern. In both arms, interviewees felt that social risk screening was acceptable in a clinic setting. Questions about immigration are timely, important, and relevant, and can be considered when implementing social assessments in communities where there are high levels of trust in providers.
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Affiliation(s)
- Elena Byhoff
- Department of Medicine, Tufts Medical Center, 800 Washington St, Box #63, Boston, USA.
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, 02111, USA.
| | - Emilia H De Marchis
- Department of Family Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Laura Gottlieb
- Department of Family Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Keith Nokes
- Tufts University School of Medicine, Boston, MA, USA
- Department of Family Medicine, Greater Lawrence Family Health Center, Boston, MA, USA
| | - Amy M LeClair
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, 02111, USA
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12
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Varley A, Montgomery AE, Steward J, Stringfellow E, Austin E, Gordon A, Pollio D, deRussy A, Hoge A, Gelberg L, Riggs K, Kim TW, Rubens SL, Kertesz S. Exploring Quality of Primary Care for Patients Who Experience Homelessness and the Clinicians Who Serve Them: What Are Their Aspirations? QUALITATIVE HEALTH RESEARCH 2020; 30:865-879. [PMID: 31894725 PMCID: PMC9271358 DOI: 10.1177/1049732319895252] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
To develop and evaluate an effective model of patient-centered, high-quality, homeless-focused primary care, our team explored key domains of primary care that may be important to patients. We anchored our conceptual framework in two reports from the Institute of Medicine (IOM) that defined components of primary care and quality of care. Using questions developed from this framework, we conducted semistructured interviews with 36 homeless-experienced individuals with past-year primary care engagement and 24 health care professionals (clinicians and researchers) who serve homeless-experienced patients in the primary care setting. Template analysis revealed factors important to this population. These included stigma, respect, and perspectives on patient control of medical decision-making in regard to both pain and addiction. For patients experiencing homelessness, the results suggest that quality primary care may have different meanings for patients and professionals, and that services should be tailored to meet homeless-specific needs.
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Affiliation(s)
- Allyson Varley
- Birmingham VA Medical Center
- University of Alabama at Birmingham
| | | | | | - Erin Stringfellow
- Missouri Institute of Mental Health, University of Missouri, St. Louis
| | - Erika Austin
- Birmingham VA Medical Center
- University of Alabama at Birmingham
| | | | | | | | | | | | - Kevin Riggs
- Birmingham VA Medical Center
- University of Alabama at Birmingham
| | | | | | - Stefan Kertesz
- Birmingham VA Medical Center
- University of Alabama at Birmingham
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13
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Byhoff E, De Marchis EH, Hessler D, Fichtenberg C, Adler N, Cohen AJ, Doran KM, Ettinger de Cuba S, Fleegler EW, Gavin N, Huebschmann AG, Lindau ST, Tung EL, Raven M, Jepson S, Johnson W, Olson AL, Sandel M, Sheward RS, Gottlieb LM. Part II: A Qualitative Study of Social Risk Screening Acceptability in Patients and Caregivers. Am J Prev Med 2019; 57:S38-S46. [PMID: 31753278 PMCID: PMC6876708 DOI: 10.1016/j.amepre.2019.07.016] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION This study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings. METHODS As part of a mixed-methods multisite study, the authors conducted semistructured interviews with a subset of adult patients and adult caregivers of pediatric patients who had completed the Center for Medicare and Medicaid Innovation Accountable Health Communities social risk screening tool between July 2018 and February 2019. Interviews, conducted in English or Spanish, asked about reactions to screening, screening acceptability, preferences for administration, prior screening experiences that informed perspectives, and expectations for social assistance. Basic thematic analysis and constant comparative methods were used to code and develop themes. RESULTS Fifty interviews were conducted across 10 study sites in 9 states, including 6 primary care clinics and 4 emergency departments. There was broad consensus among interviewees across all sites that social risk screening was acceptable. The following 4 main themes emerged: (1) participants believed screening for social risks is important; (2) participants expressed insight into the connections between social risks and overall health; (3) participants emphasized the importance of patient-centered implementation of social risk screening; and (4) participants recognized limits to the healthcare sector's capacity to address or resolve social risks. CONCLUSIONS Despite gaps in the availability of social risk-related interventions in healthcare settings, patient-centered social risk screening, including empathy and attention to privacy, may strengthen relationships between patients and healthcare teams. SUPPLEMENT INFORMATION This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.
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Affiliation(s)
- Elena Byhoff
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.
| | - Emilia H De Marchis
- Department of Family & Community Medicine, University of California, San Francisco, San Francisco, California
| | - Danielle Hessler
- Department of Family & Community Medicine, University of California, San Francisco, San Francisco, California
| | - Caroline Fichtenberg
- Social Interventions Research and Evaluation Network, Center for Health and Community, University of California, San Francisco, San Francisco, California
| | - Nancy Adler
- Lisa and John Pritzker Professor of Medical Psychology, Center for Health and Community, University of California, San Francisco, San Francisco, California
| | - Alicia J Cohen
- Providence VA Medical Center, Providence, Rhode Island; Department of Family Medicine, Brown University, Providence, Rhode Island; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Kelly M Doran
- Ronald O. Perelman Department of Emergency Medicine, New York University, New York, New York; Department of Population Health, New York University, New York, New York
| | | | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Nicholas Gavin
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Amy G Huebschmann
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado; Center for Women's Health Research, University of Colorado School of Medicine, Aurora, Colorado
| | - Stacy Tessler Lindau
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois; Department of Medicine-Geriatrics, University of Chicago, Chicago, Illinois
| | - Elizabeth L Tung
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
| | - Maria Raven
- Department of Emergency Medicine, University of San Francisco, San Francisco, California
| | - Susan Jepson
- Upstream Health Innovations, Hennepin County Medical Center, Minneapolis, Minnesota
| | | | - Ardis L Olson
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Department of Community and Family Medicine, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Megan Sandel
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| | | | - Laura M Gottlieb
- Department of Family & Community Medicine, University of California, San Francisco, San Francisco, California
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