Exploring the experiences of changes to support access to primary health care services and the impact on the quality and safety of care for homeless people during the COVID-19 pandemic: a study protocol for a qualitative mixed methods approach

Characteristics of Veterans Experiencing Homelessness using Telehealth for Primary Care Before and After COVID-19 Pandemic Onset

BACKGROUND

The COVID-19 pandemic expanded telehealth use across healthcare systems, including the Veterans Health Administration (VA). Little is known about how large-scale telehealth rollout affected access to primary care for patients experiencing homelessness.

OBJECTIVE

To examine the extent to which homeless-experienced veterans used telehealth services in primary care and to characterize users before and after the onset of the COVID-19 pandemic.

DESIGN

Retrospective cohort study, 3/16/2019-3/15/2022.

PARTICIPANTS

394,731 veterans with homelessness diagnoses nationally using 4,068,109 primary care visits.

MAIN MEASURES

The outcomes were use of 1 + telehealth visits (video, phone, secure messaging) for primary care during each year. Through multivariable regression models, we examined associations between telehealth use, patient characteristics (e.g., age, sex, race-ethnicity, comorbidity), and VA homeless services use (e.g., homeless-tailored primary care (HPACT), permanent supportive housing).

KEY RESULTS

Compared to pre-pandemic, telehealth in primary care among homeless-experienced veterans increased substantially 2 years post-pandemic (video: 1.37% versus 20.56%, phone: 60.74% versus 76.58%). Secure messaging was low over time (1.57-2.63%). In adjusted models, video users were more likely to be young (65 + years: OR = 0.43, CI: 0.42-0.44), women (OR = 1.74, CI: 1.70-1.78), Black (OR = 1.14, CI: 1.12-1.16), Hispanic (OR = 1.34, CI: 1.30-1.38), and with more comorbidities (2 + on the Charlson Comorbidity Index; OR = 1.16, CI: 1.14-1.19), compared to video non-users. HPACT patients were less likely to use video (OR = 0.68, CI: 0.66-0.71) than other primary care patients. This was not observed among users of other VA homeless services.

CONCLUSIONS

Despite decreased access to health information technology and low pre-pandemic telehealth use, veterans experiencing homelessness still sustained high use of telehealth in primary care post-pandemic. Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups. Identifying and targeting organizational characteristics (e.g., HPACT users) that predict telehealth use for improvement may be key to increasing adoption among VA primary care patients experiencing homelessness.

Barriers and facilitators to health care access for people experiencing homelessness in four European countries: an exploratory qualitative study

BACKGROUND

People experiencing homelessness (PEH) are known to be at higher risk of adverse health outcomes and premature mortality when compared to the housed population and often face significant barriers when attempting to access health services. This study aimed to better understand the specific health care needs of PEH and the barriers and facilitators associated with their timely and equitable access to health services in the European context.

METHODS

We conducted an exploratory cross-national qualitative study involving people with lived experience of homelessness and health and social care professionals in Austria, Greece, Spain, and the UK. A total of 69 semi-structured interviews comprising 15 social care professionals, 19 health care professionals, and 35 PEH were completed, transcribed, and analysed thematically.

RESULTS

Findings were organised into three overarching themes relating to the research question: (a) Health care needs of PEH, (b) Barriers to health care access, and (c) Facilitators to health care access. Overall, the general health of PEH was depicted as extremely poor, and mainstream health services were portrayed as ill-equipped to respond to the needs of this population. Adopting tailored approaches to care, especially involving trusted professionals in the delivery of care, was identified as a key strategy for overcoming existing barriers.

CONCLUSIONS

The results of this study indicate there to be a high degree of consistency in the health care needs of PEH and the barriers and facilitators associated with their access to health care across the various European settings. Homelessness in itself is recognized to represent an essential social determinant of health, with PEH at risk of unequal access to health services. Changes are thus required to facilitate PEH's access to mainstream primary care. This can also be further complemented by investment in 'in-reach' services and other tailored and person-centred forms of health care.

TRIAL REGISTRATION

This study was registered retrospectively on June 6, 2022, in the registry of ClinicalTrials.gov under the number NCT05406687.

Telemedicine in community shelters: possibilities to improve chronic care among people experiencing homelessness in Hungary

BACKGROUND

Digital health has expanded during the COVID-19 pandemic, while the exclusion of vulnerable populations with limited access to these technologies widens the gap to receive proper care. There is very little data available on the feasibility of telemedicine solutions regarding the chronic care of homeless persons.

METHODS

In our study, 75 participants experiencing homelessness were recruited from four social institutions in Budapest, Hungary. The telecare pilot service consisted of six online consultations with a physician and was available in shelters biweekly. Self-developed questionnaires were used after every online session on the originating and remote sites as well, while a follow-up study was also completed among patients after four to six months of pilot closure. Parameters as frequencies, averages, and percentage distributions were analyzed and two linear regression models were built on explaining the doctors' and patients' overall rating of visits.

RESULTS

During the pilot, 92.2% (n = 415) of originally planned visits were delivered and 55 clients (73.3%) attended the full program. Both the patients' and physicians' overall satisfaction was very high (4.52 and 4.79, respectively, on a 5-point Likert scale) and the patients' overall rating remained similarly high during the follow-up. Comparing the first and sixth visits, physicians reported significant improvements in almost all aspects. The linear regression models proved that confidence in the patients' assessment and diagnosis had the most prominent effect on the physicians' overall rating, while ease of use and lack of communication gaps influenced positively the patients' rating.

CONCLUSION

The results suggest that telehealth services represent a promising tool to ensure better care continuity while using shelter infrastructure and on-site assistance might reduce the digital exclusion of people experiencing homelessness.

"It was horrible for that community, but not for the way we had imagined": A qualitative study of family physicians' experiences of caring for communities experiencing marginalisation during COVID-19

The COVID-19 response required family physicians (FPs) to adapt their practice to minimise transmission risks. Policy guidance to facilitate enacting public health measures has been generic and difficult to apply, particularly for FPs working with communities that experience marginalisation. Our objective was to explore the experiences of FPs serving communities experiencing marginalisation during COVID-19, and the impact the pandemic and pandemic response have had on physicians' ability to provide care. We conducted semi-structured qualitative interviews with FPs from four Canadian regions, October 2020 through June 2021. We employed maximum variation sampling and continued recruitment until we reached saturation. Interviews explored participants' roles/experiences during the pandemic, and the facilitators and barriers they encountered in continuing to support communities experiencing marginalisation throughout. We used a thematic approach to analyse the data. FPs working with communities experiencing marginalisation expressed the need to continue providing in-person care throughout the pandemic, often requiring them to devise innovative adaptations to their clinical settings and practice. Physicians noted the health implications for their patients, particularly where services were limited or deferred, and that pandemic response policies frequently ignored the unique needs of their patient populations. Pandemic-related precautionary measures that sought to minimise viral transmission and prevent overwhelming acute care settings may have undermined pre-existing services and superseded the ongoing harms that are disproportionately experienced by communities experiencing marginalisation. FPs are well placed to support the development of pandemic response plans that appreciate competing risks amongst their communities and must be included in pandemic planning in the future.

"They have their security, we have our community": Mutual support among people experiencing homelessness in encampments in Toronto during the COVID-19 pandemic

Unaffordable housing is a growing crisis in Canada, exacerbated by the COVID-19 pandemic, yet perspectives of people living outdoors in encampments have primarily gone unheard. We conducted qualitative interviews with encampment residents to explore how mutual support occurred within the social context of encampments. We found that mutually supportive interactions helped residents meet basic survival needs, as well as health and social needs, and reduced common health and safety risks related to homelessness. The homelessness sector should acknowledge that encampment residents form their own positive communities, and ensure policies and services do not isolate people from these beneficial social connections.

The Impact of the COVID-19 Pandemic and Associated Societal Restrictions on People Experiencing Homelessness (PEH): A Qualitative Interview Study with PEH and Service Providers in the UK

People experiencing homelessness (PEH) faced unique challenges during the COVID-19 pandemic, including changes to accommodation availability, societal restrictions impacting access to essentials like food, and services moving to online and remote access. This in-depth qualitative research aims to add to the existing, but limited research exploring how the pandemic affected PEH. 33 semi-structured qualitative interviews (22 with PEH during the pandemic and 11 with homelessness sector service providers) were undertaken in the United Kingdom between April 2021 and January 2022. Interviews were audio-recorded, transcribed and analysed using reflexive thematic analysis. To ensure consistency of coding, 10% of interviews were coded by two researchers. The PEH sample was 50% female, aged 24-59 years, 59% white British, and included people who had lived in hostels/hotels, with friends/family, and on the streets during the COVID-19 pandemic. Providers came from varied services, including support charities, housing, and addiction services. Five key themes were identified: (i) the understanding of and adherence to public health guidance and restrictions; (ii) the experience of people accommodated by the 'Everyone In' initiative; (iii) the impact of social distancing guidelines on PEH experiences in public spaces; (iv) the importance of social support and connections to others; and (v) how homelessness services adapted their provision. Policy makers and public health communicators must learn from PEH to maximize the effectiveness of future public health strategies. Housing providers and support services should recognize the implications of imposing a lack of choice on people who need accommodation during a public health emergency. The loss of usual support for PEH triggered a loss of ability to rely on usual 'survival strategies', which negatively influenced their health. This research highlights successes and difficulties in supporting PEH during the COVID-19 pandemic and informs planning for similar public health events.

Challenges faced by people experiencing homelessness and their providers during the COVID-19 pandemic: a qualitative study

BACKGROUND

People experiencing homelessness are vulnerable to SARS-CoV-2 infection and its consequences. We aimed to understand the perspectives of people experiencing homelessness, and of the health care and shelter workers who cared for them, during the COVID-19 pandemic.

METHODS

We conducted an interpretivist qualitative study in Toronto, Canada, from December 2020 to June 2021. Participants were people experiencing homelessness who received SARS-CoV-2 testing, health care workers and homeless shelter staff. We recruited participants via email, telephone or recruitment flyers. Using individual interviews conducted via telephone or video call, we explored the experiences of people who were homeless during the pandemic, their interaction with shelter and health care settings, and related system challenges. We analyzed the data using reflexive thematic analysis.

RESULTS

Among 26 participants were 11 men experiencing homelessness (aged 28-68 yr), 9 health care workers (aged 33-59 yr), 4 health care leaders (aged 37-60 yr) and 2 shelter managers (aged 47-57 yr). We generated 3 main themes: navigating the unknown, wherein participants grappled with evolving public health guidelines that did not adequately account for homeless individuals; confronting placelessness, as people experiencing homelessness often had nowhere to go owing to public closures and lack of isolation options; and struggling with powerlessness, since people experiencing homelessness lacked agency in their placelessness, and health care and shelter workers lacked control in the care they could provide.

INTERPRETATION

Reduced shelter capacity, public closures and lack of isolation options during the COVID-19 pandemic exacerbated the displacement of people experiencing homelessness and led to moral distress among providers. Planning for future pandemics must account for the unique needs of those experiencing homelessness.

COVID-19 in Homelessness: A Worldwide Scoping Review on Vulnerabilities, Risks, and Risk Management

Homeless individuals are at greater risk of death due to social inequalities during Covid-19 pandemic. Strategies taken for general population to prevent the spread of Covid-19, such as social distance, staying at home, and observing personal hygiene are not possible for this group of people. This is a scoping review on articles published and other credible resources published analyze studies done on homeless people during the COVID-19 pandemic. In this scoping review, for the first time, we studied published articles on the situation of the homeless during the Covid-19 epidemic and by extracting and categorizing vulnerabilities, risks, as well as risk management plans, Finally we presented, useful guidance for organizations providing health and social services during the spread of diseases.

A Qualitative Study Exploring Access to Mental Health and Substance Use Support among Individuals Experiencing Homelessness during COVID-19

People experiencing homelessness have higher rates of mental ill-health and substance use and lower access to health services compared to the general population. The COVID-19 pandemic led to changes in service delivery across health and social care services, with many adopting virtual or telephone support for service users. This paper explores the experiences of access to community-based mental health and substance use support for people experiencing homelessness during the COVID-19 pandemic. Qualitative telephone interviews were conducted with 10 women and 16 men (ages 25 to 71) who self-identified as experiencing homelessness in North East England between February and May 2021. With five individuals with lived experience, results were analysed using inductive reflexive thematic analysis. Reactive changes to support provision often led to inadvertent exclusion. Barriers to access included: physical locations, repetition of recovery stories, individual readiness, and limited availability. Participants suggested creating services reflective of need and opportunities for choice and empowerment. Community mental health and substance use support for people experiencing homelessness should ensure the support is personalised, responsive to need, inclusive, and trauma-informed. The findings of this research have important implications for mental health and substance use policy and practice for individuals who experience homelessness during a public health crisis.

[Population's perceptions and experiences of the changing pattern of primary care consultations during the pandemic]

Objetivo

Explorar las percepciones y experiencias de la población general ante el impacto de la implementación de la teleconsulta en atención primaria durante la pandemia.

Diseño

Metodología cualitativa con un enfoque descriptivo-interpretativo, cuyo trabajo de campo se realizó entre mayo y noviembre de 2020.

Emplazamiento

Estudio realizado en Navarra y Euskadi.

Participantes y/o contextos

Colectivos poblacionales con distintos perfiles de ciudadanía asociada y no asociada de ambas comunidades autónomas. En total participaron 62 personas usuarias de atención primaria y se realizaron 10 grupos focales.

Método

Los grupos focales siguieron un guion semiestructurado elaborado a partir de las variables de análisis y dimensiones de interés en función de los distintos perfiles de participantes y los objetivos. Las sesiones fueron grabadas y transcritas realizándose un análisis de contenido de carácter inductivo. Se llevó a cabo la triangulación de los datos para asegurar la validez.

Resultados

La percepción de la teleconsulta por parte de la población ha ido variando a lo largo de la pandemia y ha sido heterogénea. Los/las participantes consideran que la modalidad no presencial puede repercutir en la calidad asistencial, así como amplificar las desigualdades de acceso a atención primaria.

Conclusiones

Resulta indispensable la realización de análisis y evaluaciones desde la perspectiva de equidad en salud para la toma de decisiones relacionadas con el uso de la tecnología en general y la teleconsulta en particular, en el futuro post-pandémico de la atención primaria.

Responding to COVID-19 While Serving Veterans Experiencing Homelessness: The Pandemic Experiences of Healthcare and Housing Providers

The U.S. Department of Veterans Affairs (VA) provides essential care through transitional housing and healthcare for Veterans experiencing homelessness through the Grant and Per Diem (GPD) program and the Homeless Patient Aligned Care Team (HPACT), respectively. At the onset of the SARS-CoV-2 pandemic, GPD organizations and HPACT clinics faced the challenge of being essential providers tasked with ensuring the well-being of Veterans under their care. Through semi-structured interviews with 13 providers (6 HPACT health care providers representing 2 HPACT programs, and 7 GPD staff members) across the U.S., this study explored their experiences navigating the tasks of keeping Veterans safe and providing ongoing care from the start of the pandemic up to the 2021 interview dates. Both GPD and HPACT providers reported amplified safety concerns about COVID-19 infection among staff at the start of the pandemic, which diminished to a lower, stable level after a few months as adaptations made for safety became embedded in their routines. However, ongoing challenges included isolation and mental health challenges among Veterans, inherent limitations of telehealth as a care delivery avenue, provider frustration and burnout due to increased workload and frequent change, and the logistics of administering testing for Veterans to enter GPD housing. Enhanced pandemic preparedness planning for GPD organizations, funding for personal protective equipment (PPE) and providing technology to facilitate Veterans’ telehealth access, and strategies for preventing provider burnout are critical to both sustaining homeless providers’ capabilities during this pandemic and enhancing readiness to respond to the next public health emergency.

Spillover Effects of COVID-19 on Essential Chronic Care and Ways to Foster Health System Resilience to Support Vulnerable Non-COVID Patients: A Multistakeholder Study

OBJECTIVES

Little empirical research exists on how key stakeholders involved in the provision of care for chronic conditions and policy planning perceive the indirect or "spillover" effects of the COVID-19 on non-COVID patients. This study aims to explore stakeholder experiences and perspectives of the impact of COVID-19 on the provision of care for chronic conditions, evolving modalities of care, and stakeholder suggestions for improving health system resilience to prepare for future pandemics.

DESIGN

Qualitative study design.

SETTING AND PARTICIPANTS

This study was conducted during and after the COVID-19 lockdown period in Singapore. We recruited a purposive sample of 51 stakeholders involved in care of non-COVID patients and/or policy planning for chronic disease management. They included health care professionals (micro-level), hospital management officers (meso-level), and government officials (macro-level).

METHODS

In-depth semi-structured interviews were conducted. All interviews were digitally recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Optimal provision of care for chronic diseases may be compromised through the following processes: lack of "direct" communication between colleagues on clinical cases resulting in rescheduling of patient visits; uncertainty in diagnostic decisions due to protocol revision and lab closure; and limited preparedness to handle non-COVID patients' emotional reactions. Although various digital innovations enhanced access to care, a digital divide exists due to uneven digital literacy and perceived data security risks, thereby hampering wider implementation. To build health system resilience, stakeholders suggested the need to integrate digital care into the information technology ecosystem, develop strategic public-private partnerships for chronic disease management, and give equal attention to the provision of holistic psychosocial and community support for vulnerable non-COVID patients.

CONCLUSIONS AND IMPLICATIONS

Findings highlight that strategies to deliver quality chronic care for non-COVID patients in times of public health crisis should include innovative care practices and institutional reconfiguration within the broader health system context.

The Relational Vulnerability of People Experiencing Multiple Exclusion Homelessness (MEH) in Spain

This paper draws on research analyzing the emotional and relational impacts of poverty and exclusion on charities’ clients in Spain since the 2008–2009 economic crisis, including people experiencing multiple exclusion homelessness (MEH). The study adopts a mixed-methods approach in which twenty in-depth cases were collected in different geographical locations, including twelve cases experiencing MEH. Unlike other disadvantaged groups, those affected by MEH suffer material shortages, traumatic experiences, psychological disorders, physical illnesses, and a high degree of relational vulnerability, as reflected in the structure and composition of their personal networks, which tend to be smaller in size, with just a few weak and temporary contacts, and with care professionals playing an important role. These charity users often need long-term socio-sanitary care, which challenges public and private health-care systems. Therefore, our contribution to this Special Issue is directed toward improving understanding of the relational characteristics of severely excluded people, how social support affects their personal networks, and the challenges this assistance poses to care services.

Clusters of Elements for Quality Assurance of Health Worker Protection Measures in Times of COVID-19 Pandemic

The COVID-19 (coronavirus disease) pandemic has had a significant impact on the healthcare delivery system worldwide. Many pre-pandemic norms, standards, and methods of providing medical services in most medical facilities had to be changed and re-evaluated. Many of them will likely stay changed and will probably never be provided in the same way in post-pandemic reality. The COVID-19 crisis is still ongoing and some sources say that we should be prepared for a third wave of the pandemic. The scope of the analysis conducted in this publication is related to the healthcare sector, including services and Polish healthcare professionals’ work quality during the COVID-19 crisis. The research gap, the basis for conducting new research, is the lack of clarified results analysing the quality assurance of healthcare workers during the COVID-19 pandemic. It is necessary to ask about healthcare professionals’ rate of personal protective equipment quality in Polish medical facilities. The result of cluster analysis will help us to know what the clusters for variables on quality assurance of protection measures for healthcare workers are. The research was carried out using a questionnaire survey on a sample of 21 medical personnel in Polish hospitals. The main findings of this publication are problems with information flow between staff and staff managers and determining appropriate zones. The quality of the personal protective equipment offered by medical facilities’ management and their availability is at an appropriate level. The publication aims to analyse the level of quality assurance of health care worker protection measures in the example of Silesian voivodeships in Poland during the COVID-19 pandemic.