Illness narratives of people who are homeless

Canadian Health Care Providers' Perspectives on Working with Older Homeless Adults in Outreach Settings

Service providers have a unique understanding of older homeless adults' challenges and service needs. However, research on the experiences of health care providers (HCPs) who work with this population is limited. We aimed to gain a better understanding of the experiences (roles, challenges, and rewards) of HCPs who work with older homeless adults (age 50 and over) in outreach settings. We conducted individual semi-structured interviews with 10 HCPs who worked in these roles. Four themes emerged: (a) the client-provider relationship as an essential building block to HCPs' work; (b) progression of care that acknowledges the "whole person"; (c) collaboration as integral to providers' work; and (d) the importance of system navigation. Providers found their work personally and professionally fulfilling but were frustrated by system-level challenges. Findings can be used to identify strategies on how to further support providers in their roles and enhance service provision for older homeless individuals.

Staying safe, feeling welcome, being seen: How spatio-temporal configurations affect relations of care at an inclusive health and wellness centre

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.

EQ-5D-3L Health Status Among Homeless People in Stockholm, Sweden, 2006 and 2018

Background: Homeless people are a socially excluded group whose health reflects exposures to intersecting social determinants of health. The aim of this study was to describe and compare the demographic composition, certain social determinants of health, and self-reported health among homeless people in Stockholm, Sweden, in 2006 and 2018. Methods: Analysis of data from face-to-face interviews with homeless people in Stockholm 2006 (n = 155) and 2018 (n = 148), based on a public health survey questionnaire adapted to the group, including the EQ-5D-3L instrument. The chi-squared test was employed to test for statistical significance between groups and the independent t-test for comparison of mean scores and values. Ordinary Least Squares (OLS) regression, with Robust Standard Errors (RSE) was performed on merged 2006 and 2018 data with mean observed EQ VAS score as outcome variable. Results: In 2018 more homeless people originated from countries outside Europe, had temporary social assistance than long-term social insurance, compared to in 2006. In 2018 more respondents reported lack of social support, exposure to violence, and refrained from seeking health care because of economic reasons. Daily smoking, binge drinking, and use of narcotic drugs was lower 2018 than 2006. In 2018 a higher proportion reported problems in the EQ-5D-3L dimensions, the mean TTO index value and the VAS index value was significantly lower than in 2006. In the regression analysis of merged data there was no significant difference between the years. Conclusions: Homeless people are an extremely disadvantaged group, have high rates of illness and disease and report poor health in all EQ-5D-3L dimensions. The EQ VAS score among the homeless people in 2018 is comparable to the score among persons aged 95-104 years in the general Swedish population 2017. The EQ-5D-3L instrument was easily administered to this group, its use allows comparison with larger population groups. Efforts are needed regarding housing, but also intensified collaboration by public authorities with responsibilities for homeless people's health and social welfare. Further studies should evaluate the impact of such efforts by health and social care services on the health and well-being of homeless people.

Smartphone Technology to Empower People Experiencing Homelessness: Secondary Analysis

BACKGROUND

In the United States, the number of people experiencing homelessness has continually increased over the last 3 years. Homelessness is associated with poor health, and people experiencing homelessness are often burdened with high rates of chronic and mental health conditions, functional limitations, and cognitive impairment. Despite the high burden of chronic illness and functional limitations, there is limited literature exploring self-management among homeless populations.

OBJECTIVE

This study aims to investigate how access to smartphone technology facilitates self-management, including the attainment of social needs within the context of homelessness.

METHODS

A secondary analysis of 33 exit interviews from 2 feasibility studies related to mobile health interventions among people experiencing homelessness was conducted. Iterative thematic analysis was used to identify themes representative of participants' experiences using smartphone technology.

RESULTS

Collectively, participants revealed not only how the context of homelessness constrained their ability to engage in activities necessary to self-manage health and meet social needs but also how consistent and predictable access to the tools available through a smartphone changed their behaviors and outlook. The global theme of empowered by technology was identified and defined as how having a smartphone with a plan for unlimited text, calling, data, and transportation allowed participants to navigate homelessness and facilitated self-management.

CONCLUSIONS

People experiencing homelessness used the tools on a smartphone to make decisions, take action, solve problems, and use the resources-skills necessary for fulfilling tasks required for effective self-management. Further, consistent access to smartphone technology and transportation empowered participants to meet the requirements for the attainment of social needs.

Towards Equitable Health Care Access: Community Participatory Research Exploring Unmet Health Care Needs of Homeless Individuals

Community and health services often overlook health care needs of persons experiencing homelessness, which leads to deterioration in health and increased utilization of emergency services. Since homeless people are underrepresented in health service research, little is known about their unmet health care needs, particularly in smaller cities where resources are limited. This community-based participatory research explored the experiences of small-city homeless service users (HSUs) with unmet health care needs and community service providers (CSPs) who work with them to determine barriers to health care access affecting them. Structured interviews were conducted with 65 HSUs and 15 CSPs in interior British Columbia, Canada. These interviews were audio-recorded, and the retrieved data were analyzed thematically. The three themes uncovered included: a lack of access to health care and risk of stigma, a lack of trust and fear of discrimination, and a need for community navigation and social support. The findings indicate that HSUs do not receive equitable care and face challenges in accessing appropriate and timely foot care, which contributes to increased foot-related emergency visits, loss of trust in the health care system, and disabilities due to worsening foot conditions. Various social determinants of health also impact HSUs, such as low socioeconomic status, lack of housing, decreased social support, unhealthy behaviors, and inequitable access to health services. By collaborating with HSUs, community and health services need to develop innovative outreach programs that provide better community resources as the first step toward equitable access to health care.

Hard-to-Reach Populations and Administrative Health Data: A Serial Cross-sectional Study and Application of Data to Improve Interventions for People Experiencing Homelessness

BACKGROUND

Intervention studies with vulnerable groups in the emergency department (ED) suffer from lower quality and an absence of administrative health data. We used administrative health data to identify and describe people experiencing homelessness who access EDs, characterize patterns of ED use relative to the general population, and apply findings to inform the design of a peer support program.

METHODS

We conducted a serial cross-sectional study using administrative health data to examine ED use by people experiencing homelessness and nonhomeless individuals in the Niagara region of Ontario, Canada from April 1, 2010 to March 31, 2018. Outcomes included number of visits; unique patients; group proportions of Canadian Triage and Acuity Scale (CTAS) scores; time spent in emergency; and time to see an MD. Descriptive statistics were generated with t tests for point estimates and a Mann-Whitney U test for distributional measures.

RESULTS

We included 1,486,699 ED visits. The number of unique people experiencing homelessness ranged from 91 in 2010 to 344 in 2017, trending higher over the study period compared with nonhomeless patients. Rate of visits increased from 1.7 to 2.8 per person. People experiencing homelessness presented later with higher overall acuity compared with the general population. Time in the ED and time to see an MD were greater among people experiencing homelessness.

CONCLUSIONS

People experiencing homelessness demonstrate increasing visits, worse health, and longer time in the ED when compared with the general population, which may be a burden on both patients and the health care system.

Patient safety in marginalised groups: a narrative scoping review

Background

Marginalised groups (‘populations outside of mainstream society’) experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising.

Methods

Scoping review. Systematic searches were performed across six electronic databases in September 2019. The time frame for searches of the respective databases was from the year 2000 until present day.

Results

The searches yielded 3346 articles, and 67 articles were included. Patient safety issues were identified for fourteen different marginalised patient groups across all studies, with 69% (n = 46) of the studies focused on four patient groups: ethnic minority groups, frail elderly populations, care home residents and low socio-economic status. Twelve separate patient safety issues were classified. Just over half of the studies focused on three issues represented in the patient safety literature, and in order of frequency were: medication safety, adverse outcomes and near misses. In total, 157 individual contributing or associated factors were identified and mapped to one of seven different factor types from the Framework of Contributory Factors Influencing Clinical Practice within the London Protocol. Patient safety issues were mostly multifactorial in origin including patient factors, health provider factors and health care system factors.

Conclusions

This review highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments. Such understanding provides a basis for working collaboratively to co-design training, services and/or interventions designed to remove or at the very least minimise these increased risks.

Trial registration

Not applicable for a scoping review.

Secondary care usage and characteristics of hospital inpatients referred to a UK homeless health team: a retrospective service evaluation

Background

UK “Pathway” teams offer specialist hospital care coordination for people experiencing homelessness. Emergency healthcare use is high among homeless people, yet “homelessness” is not routinely coded in National Health Service (NHS) data. Pathway team records provide an opportunity to assess patterns in admissions and outcomes for inpatients identified as homeless.

Methods

Retrospective analysis of patients referred to “Pathway” homelessness teams in seven UK hospitals to explore the patterns of hospital admission, morbidity, secondary healthcare utilisation and housing status. Each patient was individually identified as experiencing homelessness. Within a six-month period, demographic data, reason for admission, morbidity, mortality and secondary care hospital usage 120-days before and 120-days after the index admission was collected.

Results

A total of 1009 patients were referred, resulting in 1135 admissions. Most admissions had an acute physical health need (94.9%). Co-morbid mental illness and/or substance misuse was common (55.7%). Reasons for admission included mental and behavioral disorders (overdose, alcohol withdrawal or depression, 28.3%), external causes of morbidity and mortality (assault or trauma, 18.7%), and injury, poisoning and external causes (head injury, falls and fractures, 12.4%). Unplanned Emergency Department attendances reduced after index admission and unplanned hospital admissions increased slightly. Planned admissions doubled and total bed days increased. Housing status was maintained or improved for over 60% of inpatients upon discharge. Within 12 months of index admission, 50 patients (5%) died, 15 deaths (30%) occurred during the index admission.

Conclusions

Disengagement with health services is common among homeless people. Many deaths are due to treatable medical conditions (heart disease, pneumonia, cancer). Observed increases in planned admissions suggests intervention from Pathway teams facilitates necessary investigations and treatment for homeless people. Equity, parity of care, and value should be inbuilt interventions for inclusion health groups and evaluations need to move beyond simply seeking cost reductions.

Health Care While Homeless: Barriers, Facilitators, and the Lived Experiences of Homeless Individuals Accessing Health Care in a Canadian Regional Municipality

Persons struggling with housing remain significantly disadvantaged when considering access to health care. Effective advocacy for their needs will require understanding the factors which impact their health care, and which of those most concern patients themselves. A qualitative descriptive study through the lens of a transformative framework was used to identify barriers and facilitators to accessing health care as perceived by people experiencing homelessness in the regional municipality of Niagara, Canada. In-person, semi-structured interviews with 16 participants were completed, and inductive thematic analysis identified nine barriers and eight facilitators. Barriers included affordability, challenges finding primary care, inadequacy of the psychiatric model, inappropriate management, lack of trust in health care providers, poor therapeutic relationships, systemic issues, and transportation and accessibility. Facilitators included accessibility of services, community health care outreach, positive relationships, and shelters coordinating health care. Knowledge of the direct experiences of marginalized individuals can help create new health policies and enhance the provision of clinical care.

Utilization of Advance Care Planning for Homeless Adults: Case Studies

Given the barriers to advance care planning (ACP) and low utilization of outpatient advance directives in hospital settings, it is unclear if ACP in primary care for adults who have experienced homelessness is effective and a valuable use of clinical time. As part of our ACP Project, we examined the feasibility and outcomes of ACP in primary care for patients who have experienced homelessness. We found that such efforts had significant impacts on patients' hospital care and allowed their wishes to be honored when they lost capacity for medical decision-making, particularly at the end of life. Here, we present six case studies demonstrating the outcomes of ACP in primary care for homeless adults and highlight lessons learned. To our knowledge, this is the first case series showing how ACP for homeless adults in primary care has been utilized during hospital care. Based on our findings, we believe that outpatient ACP even for the most socially vulnerable patients is feasible, often impactful, and should be integrated into routine primary care.

Making sense of street chaos: an ethnographic exploration of homeless people's health service utilization

Background

Homeless people have poor health and mortality indices. Despite this they make poor usage of health services. This study sought to understand why they use health services differently from the domiciled population.

Methods

Ethnographic observations were conducted at several homeless services, in Dublin. This was supplemented with 47 semi-structured interviews with homeless people and two focus groups of homeless people and hospital doctors. A critical-realist approach was adopted for interpretation of the data.

Results

Homeless people tended to present late in their illness; default early from treatment; have low usage of primary-care, preventative and outpatient services; have high usage of Emergency and Inpatient services; and poor compliance with medication. They tended to avoid psychiatric services. A number of external barriers were identified. These were classified as physical (distance) administrative (application process for medical care; appointments; queues; the management of addiction in hospital; rules of service; and information providing processes); and attitudinal (stigma; differing attitudes as to appropriate use of services. A new form of barrier, Conversations of Exclusion was identified and described. Internalised barriers were identified which were in nature, either cognitive (fatalistic, denial, deferral to future, presumption of poor treatment or discrimination, self blame and survival cognitions) or emotional (fear; embarrassment, hopelessness and poor self-esteem). Generative mechanisms for these factors were identified which either affected participants prior to homelessness (marginalization causing hopelessness, familial dysfunction, substance misuse, fear of authority, illiteracy; mental health; and poor English) or after becoming homeless (homelessness; ubiquity of premature death; substance misuse; prioritization of survival over health; threat of violence; chaotic nature of homelessness; negative experiences of authority; and stigma.

Conclusions

An explanatory critical realist model integrating the identified generative mechanisms, external and internalised barriers was developed to explain why the Health service Utilization of homeless people differs from the domiciled populations. This new model has implications for health service policy makers and providers in how they design and deliver accessible health services to homeless people.

NEGOTIATING HEALTH: patients’ and guardians’ perspective on “failed” patient-professional interactions in the context of the Swedish health care system

Background

Sweden has a largely tax-funded health care system that aims at providing equal access for everyone. However, the individual’s perception and experience of the health care system remains a relevant topic for researchers. The aim of this study is to learn the patient’s perspective on how patients and professionals negotiate in the social context of the Swedish health care system.

Methods

Eight essays that had spontaneously been contributed to a medical writing contest were analyzed using narrative methods. Narratives were defined as a sequence of clauses that correspond to an order of events in the narrator’s biography. The analysis comprised a three-step process. First, the essays were read and narratives were extracted. Second, an agency analysis was performed. Third, an analysis of social positioning was employed.

Results

The Swedish health care system provides the social context and background for negotiations between patients and professionals. The narrators position the protagonists of the illness narratives as either patients or guardians of underage patients. The protagonists meet health care representatives in negotiation situations. Due to the lack of emotional connection between the negotiating parties, impossible situations arise. False promises are made which ultimately result in the patients’ suffering. Thus, all negotiations failed from the narrators’ perspective.

Conclusion

The narrators invited their audience to solve negotiation situations differently. This study discusses some actions that may help navigate negotiation situations: Health care providers should acknowledge the patient’s or guardian’s social position and dilemma, allow emotions, involve all parties in the decision-making process and manage expectations. Writing competitions may provide a tool for experience-based assessment of health care systems.

The Medical Treatment of Homeless People

BACKGROUND

The homeless are often in poor health, and their risk of premature death is three to four times that of the general population. This article is intended to provide an overview of the medical care of the homeless in Germany.

METHODS

We selectively reviewed pertinent scientific and non-scientific publications from the years 2000-2017 that were retrieved from PubMed, from the reports of the German Homeless Aid Society (Bundesarbeitsgemeinschaft Wohnungslosenhilfe), from the websites of homeless aid organizations, and from Google Scholar.

RESULTS

At least 75% of the homeless currently suffer from a mental illness requiring treatment. Common somatic problems include respiratory (6-14%) and cardiovascular disorders (7-20%), injuries and intoxications (5-15%), and infectious and parasitic diseases (10-16%). To circumvent the multiple barriers impeding homeless people's access to standard medical care (lack of health insurance, a feeling of being unwelcome, lack of disease awareness, impaired capacity for compliance), medical help is offered to them outside the system in a number of ways, embedded in an overall scheme of social and practical assistance with daily living. These medical resources differ from region to region. They are often underfinanced and tend to focus on acute general medical care, with limited access to specialists.

CONCLUSION

More heath care resources need to be made available to the homeless beyond standard medical care. Concrete suggestions are discussed in the text.

End-of-life care for homeless people: A qualitative analysis exploring the challenges to access and provision of palliative care

BACKGROUND

Being homeless or vulnerably housed is associated with death at a young age, frequently related to medical problems complicated by drug or alcohol dependence. Homeless people experience high symptom burden at the end of life, yet palliative care service use is limited.

AIM

To explore the views and experiences of current and formerly homeless people, frontline homelessness staff (from hostels, day centres and outreach teams) and health- and social-care providers, regarding challenges to supporting homeless people with advanced ill health, and to make suggestions for improving care.

DESIGN

Thematic analysis of data collected using focus groups and interviews.

PARTICIPANTS

Single homeless people ( n = 28), formerly homeless people ( n = 10), health- and social-care providers ( n = 48), hostel staff ( n = 30) and outreach staff ( n = 10).

RESULTS

This research documents growing concern that many homeless people are dying in unsupported, unacceptable situations. It highlights the complexities of identifying who is palliative and lack of appropriate places of care for people who are homeless with high support needs, particularly in combination with substance misuse issues.

CONCLUSION

Due to the lack of alternatives, homeless people with advanced ill health often remain in hostels. Conflict between the recovery-focused nature of many services and the realities of health and illness for often young homeless people result in a lack of person-centred care. Greater multidisciplinary working, extended in-reach into hostels from health and social services and training for all professional groups along with more access to appropriate supported accommodation are required to improve care for homeless people with advanced ill health.