Homeless health needs: shelter and health service provider perspective.

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Homeless Health Needs: Shelter and Health Service Provider Perspective a

b

Alicia J. Hauff DNP, FNP-BC & Molly Secor-Turner PhD, RN a

Department of Nursing, North Dakota State University, College of Pharmacy, Nursing, and Allied Sciences, Fargo, North Dakota b

Departments of Nursing and Public Health, North Dakota State University, College of Pharmacy, Nursing, and Allied Sciences, Fargo, North Dakota Published online: 02 May 2014.

To cite this article: Alicia J. Hauff DNP, FNP-BC & Molly Secor-Turner PhD, RN (2014) Homeless Health Needs: Shelter and Health Service Provider Perspective, Journal of Community Health Nursing, 31:2, 103-117, DOI: 10.1080/07370016.2014.901072 To link to this article: http://dx.doi.org/10.1080/07370016.2014.901072

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Journal of Community Health Nursing, 31: 103–117, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2014.901072

Homeless Health Needs: Shelter and Health Service Provider Perspective Alicia J. Hauff, DNP, FNP-BC

Downloaded by [University of Kent] at 06:09 16 November 2014

Department of Nursing, North Dakota State University, College of Pharmacy, Nursing, and Allied Sciences, Fargo, North Dakota

Molly Secor-Turner, PhD, RN Departments of Nursing and Public Health, North Dakota State University, College of Pharmacy, Nursing, and Allied Sciences, Fargo, North Dakota

The effects of homelessness on health are well documented, although less is known about the challenges of health care delivery from the perspective of service providers. Using data from a larger health needs assessment, the purpose of this study was to describe homeless health care needs and barriers to access utilizing qualitative data collected from shelter staff (n = 10) and health service staff (n = 14). Shelter staff members described many unmet health needs and barriers to health care access, and discussed needs for other supportive services in the area. Health service providers also described multiple health and service needs, and the need for a recuperative care setting for this population. Although a variety of resources are currently available for homeless health service delivery, barriers to access and gaps in care still exist. Recommendations for program planning are discussed and examined in the context of contributing factors and health care reform.

HOMELESSNESS AND HEALTH Homelessness is a global issue and numbers of homeless persons have been on the rise since the 1980s (Baggett, O’Connell, Singer, & Rigotti, 2010; Daiski, 2007). Homeless persons suffer higher rates of acute and chronic illness and mortality, as compared to the general population (Baggett et al., 2010). Homelessness poses a variety of environmental and psychosocial stressors, and basic survival is a daily goal (Davis, 1996; National Coalition for the Homeless, 2009). Survival involves a daily search for food and shelter, and attaining money and employment are constant concerns (Davis, 1996). Health problems develop due to environmental stressors and previous conditions are exacerbated, even in public shelters (Davis, 1996). The literature describes the health needs of homeless persons as complex and compounded by social, cultural, and financial barriers (Roche, 2004). Although many homeless persons lack the ability to pay for health services, other barriers to access include stigmatization, lack of continuity of care, lack Address correspondence to Alicia J. Hauff, DNP, FNP-BC, Family HealthCare, 301 NP Avenue, Fargo, ND 58102. E-mail: [email protected]

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HAUFF AND SECOR-TURNER

of trust in providers, and cultural insensitivity (Christiani, Hudson, Nyamathi, Mutere, & Sweat, 2008; Hudson et al., 2009; Hwang et al., 2010; Roche, 2004). Barriers to health care access lead to worsened health status, and homeless persons tend to prioritize the fulfillment of more basic needs such as shelter and food before seeking health care services (Martins, 2008).


HOMELESS SERVICE DELIVERY An understanding of the culture of homelessness and the multiple factors that affect health are pivotal to effective service planning and provision (Green & Rabinowitz, 2013; Hodges & Videto, 2005). When consumers are involved in decision making and planning, interventions to improve quality of life are more successful (Green & Rabinowitz, 2013; Hodges & Videto, 2005). The traditional model of homeless health service delivery is the Continuum of Care model, which places emphasis on mental health and substance abuse treatment before housing attainment (Tsemberis, Gulcur, & Nakae, 2004). The Housing First model, a newer model of homeless health service delivery, emphasizes consumer choice and harm reduction and places attainment of housing before treatment (Tsemberis et al., 2004). Some evidence suggests the Housing First model aids in housing retention without increasing use of substances (Tsemberis et al., 2004). Case management, sufficient time and assistance with transition to housing, and relearning skills necessary to retain housing are necessary (Meschede, 2011). Another emerging model of care in homeless service delivery is Trauma-Informed Care (TIC; Hopper, Bassuk, Olivet, 2010). TIC rests on the premise that homelessness and associated experiences are traumatic, and many homeless persons have endured traumatic events that negatively affect their health outcomes (Hopper et al., 2010). Similar to the harm reduction principles of the Housing First program, TIC involves trauma awareness and understanding, emphasis on safety to avoid re-traumatization, opportunities to regain control, and the use of a strengths-based approach to focus on clients’ strengths and skill building (Hopper et al., 2010). Review of the evidence indicates providers need more education about TIC and dealing with trauma issues in clients (Hopper et al., 2010). Clients want services that are empowering, while mental health services are important for most homeless persons and families (Hopper et al., 2010). In addition to general service provision models, homeless persons may also experience unique needs related to discharge planning following hospitalization. For example, upon discharge homeless persons may be too ill to reside in shelters or be on the streets yet not ill enough to remain hospitalized (Health Care for the Homeless Clinicians’ Network [HCHCN], 2007; Zerger, Doblin, & Thompson, 2009). In response to this gap in care, medical respite care programs began providing medical care and support services in Washington DC and Boston, MA in the mid-1980s (HCHCN, 2007). Respite programs across the nation are characteristically innovative, tailored to fit communities’ needs, and offer comprehensive medical and social support (Zerger et al., 2009). Homeless persons tend to rely on hospital emergency departments for services, which are often medically least appropriate and the most costly (Zerger et al., 2009). Homeless persons also have higher rates of hospitalizations than the general public (Zerger et al., 2009). Other factors contributing to respite care needs include rising costs of health care, lack of health care insurance, lack of access to Medicaid benefits, and shorter hospital stays (Zerger et al., 2009). A growing body of evidence supports respite programs’ positive effects on homeless health and reduction of health care costs related to decreased hospitalizations and emergency room use (Buchanan,

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Doblin, Sai, & Garcia, 2006; Sadowski, Kee, VanderWeele, & Buchanan, 2009; Zerger et al., 2009). The effects of homelessness on health are well documented, though less is known about the challenges of health care delivery from the perspective of service providers. The purpose of this study was to describe homeless health care needs and barriers to access utilizing interview data collected from shelter and health service staff in a larger community health needs assessment.


METHODS The data for this study were part of a larger community needs assessment that utilized a mixedmethods design to describe and document the health needs of the Fargo, ND and Moorhead, MN chronically homeless population from the perspectives of consumers and service providers. Recruitment Convenience sampling was used to recruit staff from five area shelters, two permanent supportive housing establishments, two area hospitals, a homeless health clinic, and public health departments. Service providers were recruited with assistance from Fargo-Moorhead Coalition for Homeless Persons members and staff from each site. Participants were recruited via e-mail invitation with information about the project. Data Collection Data from this study were collected in two phases. In phase one, 10 individual interviews were conducted with local shelter staff. In phase two, 14 individual interviews were conducted with health service providers. All interviews lasted from 20 min to 90 min and were digitally recorded in a private location selected by participants. A semistructured interview guide was developed to address the following content areas (see Tables 1 and 2). The interview guide incorporated some questions from the Medical Respite Development Workbook, in addition to questions developed by the authors (Jaco, 2011). Additional probes and follow-up questions were used as necessary

TABLE 1 Shelter Staff Interview Question Guide (n = 10) Interview Theme Health needs Barriers to care Respite care needs

Support service

Questions What are common health care needs of homeless individuals you encounter? What do you see as barriers to their access of health care or having health needs met? How many people continue to need a bed during the day due to illness? (Jaco, 2011) How often do you encounter homeless persons who require health care beyond the shelter setting that may benefit from respite care? Are day beds provided? (Jaco, 2011) What support services are needed but not currently provided by the needs shelter? (Jaco, 2011) Is any health care provided at the shelter?

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TABLE 2 Health Service Provider Interview Question Guide (n = 14) Interview Theme Health needs


Barriers to care Discharge planning

Respite care needs

Support service needs

Questions What do you know about the health care needs of homeless persons you encounter? How do you work to meet their health needs? How often do you encounter patients experiencing homelessness? (Jaco, 2011) What are the most common medical problems or needs you see in patients experiencing homelessness? (Jaco, 2011) What do you see as barriers to their access of health care or having health needs met? Do you assess housing status in order to determine whether patients are experiencing homelessness? (Jaco, 2011) How long, on average, do homeless patients stay in the hospital? (Jaco, 2011) How does average length of stay for homeless patients compare to average length of stay for housed patients? (Jaco, 2011) Are any discharge policies in place for patients experiencing homelessness? (Jaco, 2011) Is discharge planning difficult for patients experiencing homelessness? To where are they usually discharged? (Jaco, 2011) How often do you encounter homeless patients who would benefit from medical respite care? How might the availability of medical respite care improve your patients’ health care needs? What support services do homeless clients need following hospital discharge? (Jaco, 2011) To your knowledge, what services or programs are provided or available to help meet their needs in any course of care?

to allow for additional discussion with participants. Institutional Review Board approval was obtained through North Dakota State University and other participating agencies as necessary.

Data Analysis Descriptive content analysis methods were used to identify themes and patterns among interview data (see Tables 3 and 4). Interview audio files were transcribed and coded based on the content of the structured interview guide to categorize participants’ perspectives of homeless health needs, contextual factors, and current resources. Direct quotations were transcribed verbatim and selected based on their reflection of the theme and the ability to capture participants’ full messages and tones.

RESULTS Shelter Staff Perspective Shelter staff spoke primarily about three central issues of concern: (a) health problems and needs, (b) barriers to appropriate care, and (c) medical respite and support service needs.


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TABLE 3 Shelter Staff Interview Themes (n = 10) Health needs among shelter residents • Many unmet needs • Diabetic cares, supplies • Acute, chronic and undiagnosed conditions • Cultural competence among providers • Dental • Injury care • Poor diet • Pain treatment • Rapid hepatitis testing Barriers to health care access and unmet needs • Transportation • Lack of insurance, affordability of health care • Physical or mental limitations • Lack of trust in health system or providers • Inability to prioritize health care needs above work, shelter, meals • Lack of physical address • Limited homeless health clinic hours Respite care needs • One bed available at some shelters • Residents who could benefit from respite care frequently to occasionally encountered • Residents with conditions need to be independent with cares, mobile Support service needs • More case management • Trauma-Informed Care • Housing First model • Nursing staff able to do hands-on care

• Needle exchange program • Hospice • Medication assistance, storage • Medical supplies, equipment • Transitional level of care • Safe place to rest, recuperate • Infectious disease isolation • Sexual assault care • Supportive services • Stigma, discrimination in care • Providers’ judgment of patient needs • Lack of knowledge of resources • Long wait for specialty care • Limited nursing care in shelters • Application for disability benefits complex

• Staff often unable to accept patients from hospital • Shelter nurses’ scope of practice excludes hands-on care • No medical supervision in shelters • Place for residents to exercise • More nursing staff • More affordable housing • More medical questions on intake form

Health problems and needs. Shelter staff members cited health needs among homeless residents primarily associated with acute, communicable conditions and chronic conditions that worsen. According to one participant, some conditions remain undiagnosed or untreated, which sometimes leads to fatalities. Communicable diseases were cited as commonly attributed to the dorm-style living conditions and shared spaces in shelters. Some residents with communicable conditions need isolation or a room of their own. When you just have a simple fever that could be contagious, or any kind of contagious thing, it would help all of us if they were not here while they were contagious. . . . We try hard to wash handles on doors; we try hard to wear gloves. . . . It would be great to know when somebody had a fever. . . . Just for 24 hours they could be somewhere else. If they’re already our resident, we handle that appropriately. But when you’re bringing someone in from the community that exposes the other community and it’s just a trickle effect, so there is no place for isolation here. (Female shelter staff participant)

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TABLE 4 Health Service Provider Interview Themes (n = 14) Health needs among homeless consumers • Similar to general population • Counseling • Rehabilitation, life skills training • Subacute needs • Isolation for infectious disease Barriers to health care access • Transportation • Difficulty coordinating care • Lack of insurance/finances • Diminished self-worth • Fear of judgment • Mental, physical limitations • Substance abuse • Limited hours at homeless health clinic • Low prevalence of treatment first principles Discharge planning • Difficult to place • Often need cares beyond shelter capabilities • Detox/crisis center if intoxicated • Bus station • Estrangement from family • Shelters often full Services needed • Transitional level of medical care • Hands-on nursing care • More shelter staff • Shelter case management Respite needs • Frequent need among homeless patients, residents • Risks for hospital readmission

• Primary/consistent care • Dental care • Prescription assistance • Safe place to store belongings • Comorbid conditions • Limited access to substance abuse treatment in North Dakota and Minnesota • Lack of trust in providers • Inability to prioritize health care • Lack of life skills • Societal views of homelessness • Stigmatization • Long wait lists for psychiatric care • Limited affordable housing • Delayed discharge • No transitional level of care • Shelter staff hesitant to accept discharged patients • Difficulty securing medical supplies • Home needed to provide home services • Long-term care • Housing First model • More affordable housing • Trauma-informed care/harm reduction training • Shelters unable to provide step-down level of care

Diabetes was cited by almost all shelter staff members when asked about health needs they encounter. Foot and leg problems were reported as “rampant” among residents, especially for diabetic residents. Some residents need recuperation for mental health needs, which may worsen in a stimulating shelter environment. Most shelter staff members said that mental health needs are often tied to residents’ medical state and any chronic health conditions they may have. Barriers to care. Many of the health care needs reported by shelter staff members were tied to barriers to access or fulfillment of needs, such as lack of insurance and inability to afford care. Medications are often lost, stolen, or unaffordable. All shelter staff members cited transportation as a common barrier. One shelter staff participant remarked on the difficulty of navigating the health care system among multiple barriers presented with homelessness.


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I think of . . . how fortunate it is to have health insurance . . . but how still difficult it is to get your doctors’ appointment, go there, find out what’s wrong, get your meds, have the meds work . . . even having health care insurance is hard for us. And then if you have all these other barriers of not having a home, of not having health insurance, not having transportation, not having an advocate. . . . I mean, that’s very challenging for them, even more so, because I’m challenged in the health care field trying to take care of myself and my family. I can’t imagine not having the resources that I have, and they don’t have those resources. (Female shelter staff participant)

Shelter staff members discussed the difficulty diabetic residents have in regulating blood sugars due to lack of supplies and a clean space in which to use them, as well as barriers to proper nutrition. For example, foods donated to shelters often contain sugars and starches, making blood sugar regulation for diabetic residents difficult. Three shelter staff members also discussed a high incidence of unreported sexual assault among female residents and difficulty connecting with appropriate care while avoiding retraumatization. They described a lack of established medical care and appropriate counseling for such residents. Because many residents do not report the assaults, staff members provide support without adequate training and debriefing. Assaulted residents turn to shelter staff for support, and staff struggle to advocate for them. We’ll have people that come and maybe they’ve just been abused, and I want them to be assessed because there’s no provider here. Sometimes they’re afraid to go out, thinking their abuser’s going to see them, if they have a car. And to send them on a bus is scary, too, because they maybe have never ridden a bus, they don’t even know where they’re going, they’re afraid. (Female shelter staff participant)

In addition to these barriers, some shelter staff members also described perceived barriers such as resistance to seek health care due to lack of trust in providers or the health care system. One shelter staff member described a homeless patient who experienced significant pain and was not prescribed pain medication because the physician feared the homeless patient would sell his medication. Establishing trust among homeless patients requires additional effort. One shelter staff member commented that it takes her a minimum of 3 weeks to build trust with residents to connect them with a primary care provider, and residents do not readily commit to seeing one provider for their needs. In addition, many residents are unable to prioritize their health needs above other needs, and desire to work rather than go to a clinic. Other barriers to access included physical and mental illness, long wait times for appointments for specialty care, lack of knowledge of resources, and limited nursing care at shelters. Medical respite and support service needs. Most shelter staff members stated that medical respite is a frequent need among the residents they encounter. Shelter staff members spoke of receiving calls from hospital staff members for patients with medical needs beyond what staff could handle, and they were required to turn them away. Shelter staff members stressed that residents must be independent with any medical cares because no medical staff people are available to assist or monitor at the shelters. They described performing tasks outside of their training and experience. For example, residents with limited physical mobility may have a walker or wheelchair, but may still require assistance with transferring by staff members or other residents not trained to do so. They emphasized that normally sick persons have a home to be discharged to recuperate from illness, but that there is currently no alternative in the community. The need

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for both a transitional level of care and learning how to perform tasks to accommodate the needs of medically fragile residents was described by one shelter staff member as follows: Even if they don’t appear to have a health-related emergency or situation on their hands at that moment, so many of them have diabetes and high blood pressure and heart conditions . . . so much lung disease, foot and leg problems . . . and really their bodies could use a break if they just had a place to be. . . . But as far as any chronic stuff, like those folks . . . should not be outside. . . . At any given time we could have three or four guests in a medically vulnerable respite-type situation. . . . I get tons of calls . . . for people who needed to come here who in no way shape or form are we equipped to serve. . . . I think hospitals are doing a better job of trying to discharge people to something. . . . I’ve learned a ton about oxygen in the last 6 months because of hospice and everything else. . . . It’s one of those accidental things. (Female shelter staff participant)

In addition to the health-related needs described, shelter staff members also identified additional support services that would contribute to improved health among homeless residents. For example, within shelters, five shelter staff members explained the need for more case management personnel, nurses at each shelter to perform hands-on care, and adequate funding for transportation services. One shelter staff participant commented on the need for a place where residents could exercise and obtain healthier meal options. Other services identified were long-term psychiatric care, addiction counseling, and medical assistance revision. In addition, two shelter staff members felt there was a need in the community to improve health care providers’ understanding of cultural competence and trauma informed care principles. One shelter staff member described this as follows: Better education in the health care system. . . . I have witnessed first-hand what happens to the uninsured or underinsured especially if they’re repeat visitors. . . . You know I want to just sit that nurse or doctor down and say, “Listen, do you realize that if we just invest in programs that kept people from getting this sick in the first place, that you wouldn’t deal with this anymore, and you as a community member would save a ton of money in health care costs and insurance?” . . . We’re very committed to crisis-driven care. . . . So that’s a big piece too, the ways that people are treated is just unbelievable. . . . And, again, I think that every individual out there doing that is a good person, something just happens . . . in the system. . . . They don’t realize that the person they’re looking at is trying to survive. This is truly survival. They’re not just trying to come in and be a pain. . . . It’s survival.” (Female shelter staff participant)

Health Service Provider Perspective Health service providers’ responses were similar to those of shelter staff members. They spoke of concerns related to (a) health needs and barriers to care management, (b) issues with discharge planning, and (c) respite and support service needs. Health needs and barriers to care management. Some health service providers described homeless health needs as similar to those of the general population, but with significantly more barriers to management. One participant described that homelessness, itself, is an unmet health need, and health is not a priority if a person does not have a home. Medical needs of homeless patients were described as complex and increasing with limited ability to treat comorbid issues.


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Seems like we have issues all the time, especially someone just needing a couple day’s worth of antibiotics, or something that they can’t go to the shelter because there isn’t a nurse there long enough to help assist them. . . . There’s always a need. Something simple, too, just to get oxygen for a couple days . . . keep their O2 saturations up after getting over a pneumonia, that’s really common. However, it’s really frowned upon in the local shelters. I find isolation and any infectious disease to be a barrier sometimes. It used to be, 10 years ago when I started here, the big thing was, “Are they HIV positive?” But now we’re talking, you know, CRE, KPC, MRSA, CDIFF, and we have these bigger superbugs that are becoming so much more commonplace. . . . So it becomes something as simple as changing your socks or showering in a homeless shelter can become an infection problem. . . . I find the problems are getting bigger and bolder around here, with the shelters being full, and the medical things . . . even a wound vac for a week becomes an issue. . . . They’re more complex patients that are being discharged to the shelters. (Nurse case manager)

Patient loads inclusive of homeless individuals varied and depended on work setting, role, and time of year. During the winter, homeless patients exhibited a higher level of needs with conditions exacerbated by cold, such as congestive heart failure, chronic obstructive pulmonary disease, hypothermia, and loss of digits. Emergency room staff members reported encountering homeless patients daily for medication needs, exposure to cold, detoxification, or for food and temporary shelter. Homeless patients were reported to seek health care sporadically or for emergent needs, and many do not see a primary care provider. Homeless persons are often offended by providers or fear judgment, and some lose trust in providers to the point of unwillingness to return for care. Some participants said that it takes weeks to establish trust with homeless patients or residents at a minimum. One health service provider described how mistrust among homeless patients may be related to an increased prevalence of trauma, abuse, and exposure to violence at a younger age, which may impair their ability to cope and work through conflict. In addition, as the following health service provider described, mental illness and cultural stigmatization may be barriers to accessing health care. I think the biggest barrier, though, is the same barrier that makes somebody homeless in the first place, which is inability to prioritize care. And that’s often a very organic inability that comes from mental illness. And I think in our country, in general, we do not treat mental illness like other illnesses. . . . We have a mind–body separation that’s very clear and distinct. Other countries have managed to integrate that a lot better than we have . . . As long as you have money and insurance, you can see psychiatry and get medications and you can better manage those things . . . but if you don’t, you’re just kinda out of luck. And we also just don’t take care of people who simply can’t take care of themselves. We need to judge them; we need to say the reason is because they refuse this or they won’t do that, they’re lazy or they, you know, want to use the system . . . and it’s just not the case. . . . And I think that we just don’t value people who we consider to be as highly functioning as we think people should be . . . and that extends to how much care they should receive, even how much compassion they should receive. . . . We can’t be okay with saying, you know, some people just need to be taken care of. . . . There’s an innate moral and ethical obligation to care for people who can’t. (Registered nurse)

Barriers related to mental health are complicated by limited access to appropriate substance abuse treatment services. One participant discussed the programs available for homeless persons with co-occurring mental illness and chemical dependency in contrast to the limited resources for those with chemical dependency alone. Harm reduction principles are utilized in the presence of co-occurring mental illness and chemical dependency, but not for chemical dependency alone.

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Only traditional sobriety-based programs are available for substance abuse treatment, which were said to be ineffective.


Discharge planning. Health service providers collectively voiced that discharge planning for homeless patients is difficult. Homeless patients were said to be medically stable to leave the hospital, but still in need of basic medical care that is not available in shelters or on the street. Some providers voiced concerns about homeless patients’ ability to access appropriate resources after discharge, as well as the scarcity of appropriate places for discharge. Other participants said that hospital discharge may be delayed if an appropriate place is not available, and length of hospital stay would be longer. We could just all confirm it’s [length of hospital stay] longer. If they need assistance or services, it will be longer. We don’t have programs designed for homeless after care. And weather does make a difference on that. You just can’t send somebody out with no clothes, no home, and no plan when it’s twenty below out. You have to at least try to come up with some way to help. (Social worker)

Medical respite and support service needs. Health service providers corroborated the need for a medical respite facility in the community. Relationships were reportedly strained among hospital and shelter staff members because of the lack of a postacute level of care for homeless persons. Hospital staff members are obligated to discharge patients who are medically stable, but shelter staff are unable to provide medical care for recuperation. Service providers describe how a respite care program could be a place to connect homeless patients with services and resources, facilitate recovery from illness or surgery, store and administer medication, and provide an opportunity to perform in-depth education. Service providers in the hospital setting viewed a respite program as beneficial for nearly all homeless patients, including those in supportive housing. Respite care was also viewed as potentially a significant cost-saving program, and a solution to address the need for a transitional level of care in the community. It [respite program] sounds wonderful. . . . I think most people agree that Housing First is the goal, but until we get there, and I don’t know that we ever can get there because it keeps growing, it’d be really nice to have something to be able to look at whether it’s a day or a week even. . . . In the long, run it would probably save the health system a lot of money . . . Who pays for that? . . . I think if we saw the Cooper House and Gateway Gardens and the Gladys Ray shelter, I believe anything’s possible if you get the right people in the room. . . . It’s too good to be true. . . . To go directly to living in a shelter where you have to walk the streets all day is, a lot of times, a recipe for readmission and failure because truthfully any of us who have been hospitalized know, what do you do the first couple of days, you just want to lay down . . . That transition period may not keep them from being homeless in the future, but be huge in that ability to get somebody to a strength level that they can . . . be able to do the things they need to do to prepare for housing . . . could really be huge for the health care system and those people. . . . The conversation in the community has been long-standing about if you just keep putting all the money into shelter beds, that’s the only resource we’re gonna have. (Social worker)

Health service providers expressed concerns about the limited hours and scope of shelter nurses, and many agreed that more nursing staff members who could provide hands-on care are needed. Some health service providers said that shelters could use more staff members in general. Other concerns were voiced regarding service delivery for mental health and substance abuse.


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Our providers can prescribe psychiatric medications and so we are often the gap filler for the mental health providers because it is so hard to get in to see psychiatry. So our providers will prescribe medications until they get hooked up with the appropriate services. . . . We have a very traditional approach to substance abuse in North Dakota, and our patients do not fit well in those. . . . That real traditional approach, too, kind of shame-based, in your face, sobriety and abstinence is the only acceptable option, doesn’t work for these patients. We have a dual-diagnosis treatment program through [agency] but their capacity is so limited and those individuals that they serve are dually-diagnosed so they have to have serious, persistent mental illness to be qualified. . . . A lot of our patients have never been diagnosed . . . so they don’t really fit that criterion. . . . So that’s a really big barrier that I see for some of the more vulnerable, high-risk individuals that are out there that have never been engaged in services . . . because nobody’s looking at the fact that these are very chronic individuals that will probably never stop drinking or stop using, but we can reduce the harm. (Social worker)

The harm reduction approach described was recommended by this participant for use by all service providers working with homeless persons. Health insurance coverage for substance abuse treatment was also a concern, as many homeless persons have never been engaged in services and lack health insurance. Long-term housing for people who cannot care for themselves was also viewed as a need. It [homelessness] was directly related to the deinstitutionalization, and all those places shut down and all of a sudden we started seeing a lot of homeless people who had a lot of severe mental illness because there was nowhere else for them to go. Their homes were shut down . . . and this is where we are now. . . . We need more long-term care. . . . We don’t have long-term care facilities to help people recover. . . . I think that we still aren’t addressing that we need some of those institutions back. . . . I know that we have a much too loose definition of what’s considered potential for harm to self or others. . . . So I think we’ve swung too far . . . the other way; we need to back it up a little and say, “You know what, sometimes people are hell-bent on destroying themselves and we have to intervene.” (Registered nurse)

DISCUSSION Similar to previous research, this study identified several barriers to health among homeless individuals such as lack of transportation, health insurance, or a permanent address confounded by a lack of trust in health care providers, mental illness, and substance abuse (Martins, 2008; Nickasch & Marnocha, 2009). Findings from this study and others suggest a significant gap in care for homeless individuals who are discharged from hospitals yet still require medical care (HCHCN, 2007; Zerger et al., 2009). Hospital staff members are required to discharge patients as soon as “medically stable” yet shelters are not equipped to accommodate their health needs (HCHCN, 2007). Sometimes discharge must be delayed because another level of care cannot be accessed, or shelters must turn patients away with needs beyond what can be accommodated (HCHCN, 2007). Shelter staff members attempt to accommodate the needs of these residents, but shelter resources are limited. Homeless patients may not be able to comply with discharge instructions and treatment, and without needed recuperation, may be readmitted (HCHCN, 2007). Inclement weather further complicates discharge efforts. Service providers perceived a respite program as a place for discharged patients to rest and recuperate, access supportive services, and receive medical care

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as needed. Medications could be stored and administered, in-depth education could be provided, and care would be provided for physical and mental health needs. A respite program in the FargoMoorhead community may prove to be a cost savings for the community and health systems, albeit one of many solutions to address the needs of the homeless population (Zerger et al., 2009).

IMPLICATIONS


Practice and Provider Education Data from this needs assessment revealed the need for service provider education about homelessness, cultural competence, and trauma-informed care principles, as previously documented in the literature (Martins, 2008; Nickasch & Marnocha, 2009). They may also benefit from education about sexual assault, harm reduction, and trauma-informed care principles, as well as available resources in the community (Hopper et al., 2010; Tsemberis et al., 2004). Service providers must reflect on their own attitudes and understanding of homelessness and cultural sensitivity. The need for a medical respite care program was established. Recommendations for further planning included community member collaboration to determine an appropriate respite model based on needs and available resources, and defining next steps for funding and development (McMurray-Avila, Ciambrone, & Edgington, 2009). Respite models vary by type of facility, level of medical care, and support services offered with corresponding advantages and challenges (McMurray-Avila et al., 2009). The two primary models are freestanding respite units and shelter-based models, although emerging models are located in transitional or permanent supportive housing facilities and residential treatment centers (McMurray-Avila et al., 2009). Policy Medicaid expansion and coverage. Universal access to affordable health care is “essential in the fight to end homelessness” and would “reduce the fiscal impact and social cost of communicable diseases and other illnesses” (National Coalition for the Homeless, 2009). Significant change is underway with implementation of the Patient Protection and Affordable Care Act [ACA] (National Health Care for the Homeless Council [NHCHC], 2012a). The expansion of Medicaid eligibility requirements will greatly impact the homeless population (NHCHC, 2012a). Medicaid coverage significantly improves access to providers and needed services, leading to continuity of care and management of health conditions (Kaiser Commission on Medicaid and the Uninsured [KCMU], 2012). Medicaid expansion has been found to improve utilization of preventive care interventions, increase the probability of having a regular office or clinic for primary care, and improve self-reported health (Department of Health and Human Service, 2012). Homeless persons encounter many barriers to Medicaid enrollment in spite of eligibility, including lack of trust, language and literacy barriers, lack of transportation, lack of documentation and stable contact information, and mental health disorders (KCMU, 2012) . The ACA requires states to


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conduct outreach to and enroll vulnerable and underserved populations eligible for medical assistance . . . including children, unaccompanied homeless youth, children and youth with special needs, pregnant women, racial and ethnic minorities, rural populations, victims of abuse or trauma, individuals with mental health or substance-related disorders, and individuals with HIV/AIDS. (NHCHC, 2012a, p. 2)


Active outreach efforts, relationship-building efforts to establish rapport and trust, and education of individuals about Medicaid coverage are beneficial in decreasing barriers to enrollment (Altman, 2012; KCMU, 2012). ACA and medical respite programs. ACA provisions aim to improve quality of care, reduce costs, and address comprehensive care management and discharge planning (NHCHC, 2012b). Until medical respite is established as a baseline service by the Department of Health and Human Services, states are encouraged to use existing options under Medicaid to support medical respite programs (NHCHC, 2012b). Two options that could be used by states to support their medical respite programs include a state plan amendment to provide targeted home and community-based services under Section 1915(i) of the Social Security Act and a demonstration waiver under Section 1115 of the Social Security Act. (NHCHC, 2012b, p. 2)

Federally qualified health centers and Health Care for the Homeless grantees may also apply for addition of recuperative care to their scope of services (NHCHC, 2012b). However, collaboration is necessary among other stakeholders such as the Department of Veteran Affairs, local hospitals, and Department of Housing and Urban Development to provide stable funding for respite programs (NHCHC, 2012b). Affordable housing. Study participants cited a significant need for more affordable housing both locally and across the state of North Dakota. Political advocacy is needed at the local, state, and federal level to direct energy and funds to address this need. Barriers to securing and maintaining housing also need to be addressed. Housing is the base solution to the Housing First model and breaking the cycle of homelessness (Tsemberis et al., 2004). Research The use of a mixed-methods design in the larger study proved to be beneficial for thorough assessment of homeless health needs among both consumers and service providers. However, data collection tools used need to be refined and further validated in other community homeless health needs assessments. Communities may desire to perform periodic health needs assessments or following the implementation of select interventions. This project adds to the growing body of knowledge of homeless health needs, though further research in other communities may be beneficial. In addition, health needs assessments or other research of the health care needs of homeless teens and young adults, homeless families, and homeless persons in rural areas would also be beneficial.

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SUMMARY


Findings from this project echoed findings from current literature. Homelessness is a direct threat to health, and the importance of addressing homeless persons’ basic needs must be balanced with needs for health care and supportive services. Gaps in care must be addressed in homeless health service delivery to ensure quality care and reduce costs. Service providers must recognize the need for harm reduction in service provision and appropriate long-term solutions to prevent homelessness. Community stakeholders must be informed and involved in taking action to address homeless persons’ barriers to health care access and corresponding health disparities. REFERENCES Altman, D. (2012). How the ACA can help the homeless. Retrieved November 14, 2012, from http://www.kff.org/ pullingittogether/altman_aca_help_homeless.cfm. Baggett, T. P., O’Connell, J. J., Singer, D. E., & Rigotti, N. A. (2010). The unmet healthcare needs of homeless adults: A national study. American Journal of Public Health, 100, 1326–1333, doi:10.2105/AJPH.2009.180109. Buchanan, D., Doblin, B., Sai, T., & Garcia, P. (2006). The effects of respite care for homeless patients: A cohort study. American Journal of Public Health, 96, 1278–1281. Christiani, A., Hudson, A., Nyamathi, A., Mutere, M, & Sweat, J. (2008). Attitudes of homeless and drug-using youth regarding barriers and facilitators in delivery of quality and culturally sensitive health care. Journal of Child and Adolescent Psychiatric Nursing, 21(3), 154–163, doi:10.1111/j.1744-6171.2008.00139.x. Daiski, I. (2007). Perspectives of homeless people on their health and health needs priorities. Journal of Advanced Nursing, 58, 273–281. Davis, R. E. (1996). Tapping into the culture of homelessness. Journal of Professional Nursing, 12(3), 176–183. Department of Health & Human Services. (2012). Medicaid. Retrieved from http://www.healthcare.gov/using-insurance/ low-cost-care/medicaid/. Green, L. W., & Rabinowitz, P. (2013). PRECEDE–PROCEED. Retrieved from http://ctb.ku.edu/en/tablecontents/ sub_section_main_1008.aspx. Health Care for the Homeless Clinicians’ Network. (2007). Medical respite care: An integral part of the homeless care continuum. Retrieved from http://www.nhchc .org/Healing%20Hands/HealingHandsApril2007.pdf. Hodges, B. C., & Videto, D. M. (2005). Assessment and planning in health programs. Sudbury, MA: Jones and Bartlett. Hopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from the storm: Trauma-informed care in homelessness services settings. Open Health Services and Policy Journal, 3, 80–100. doi:10.2174/1874924001003020080. Hudson, A. L., Nyamathi, A., Greengold, B., Slagle, A., Koniak-Griffin, D., Farinaz, K., & Getzoff, D. (2009). Healthseeking challenges among homeless youth. Nursing Research, 59, 212–218, doi:10.1097/NNR.0b013e3181d1a8a9. Hwang, S. W., Ueng, J. J. M., Kiss, A., Tolomiczenko, G., Cowan, L., Levinson, W., & Redelmeier, D. A. (2010). Universal health insurance and health care access for homeless persons. American Journal of Public Health, 100, 1454–1461, doi:10.2105/AJPH.2009.182022. Jaco, M. (2011). Medical Respite Program Development workbook. Nashville, TN: National Health Care for the Homeless Council. Kaiser Commission on Medicaid and the Uninsured (KCMU). (2012). Medicaid coverage and care for the homeless population: Key lessons to consider for the 2014 Medicaid expansion. Retrieved from http://www.kff. org/Medicaid/ upload/8355.pdf Martins, D. C. (2008). Experiences of homeless people in the health care delivery system: A descriptive phenomenological study. Public Health Nursing, 25, 420–430, doi:10.1111/j.1525-1446.2008.00726.x. McMurray-Avila, M., Ciambrone, S., & Edgington, S. (2009). Medical respite services for homeless people: Practical planning. Retrieved from http://www.nhchc.org/wp-content/uploads/2011/09/FINALRespiteMonograph1.pdf. Meschede, T. (2011). From street life to housing: Consumer and provider perspectives on service delivery and access to housing. Cityscape: A Journal of Policy Development and Research, 13(1), 71–90. National Coalition for the Homeless. (2009). Substance abuse and homelessness. Retrieved from http://www. nationalhomeless.org/factsheets/addiction. html.



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National Health Care for the Homeless Council. (2012a). Medicaid expansion & the ACA: Issues for the HCH community. Retrieved from http://www.nhchc.org/wp-content/uploads/2011/10/PolicyBrief-Medicaid Expansion-Sept20121.pdf. National Health Care for the Homeless Council. (2012b). Medical respite care and homelessness. Retrieved from http:// www.nhchc.org/wp-content/uploads/2011/09/ 2012-Medical-Respite-Policy-Statement-doc.pdf. Nickasch, B. & Marnocha, S. K. (2009). Healthcare experiences of the homeless. Journal of the American Academy of Nurse Practitioners, 21, 39–46, doi:10.1111/j.1745-7599.2008. 00371.x. Roche, B. (2004). Multiple health needs and homeless people. Primary Health Care, 14(7), 20–22. Sadowski, L. S., Kee, R. A., VanderWeele, T. J., & Buchanan, D. (2009). Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: A randomized trial. Journal of American Medical Association, 301, 1771–1778, doi:10.1001/jama.2009.561 Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 94, 651–656. Zerger, S., Doblin, B., & Thompson, L. (2009). Medical respite care for homeless people: A growing national phenomenon. Journal of Health Care for the Poor and Underserved, 20, 36–41, doi:10.1353/hpu.0.0098.

Feasibility of shelter-based mental health screening for homeless children.

[Reembursing health-care service provider networks].

Nutrition and health services needs among the homeless.

Complex health conditions and mental health training: How prepared is the frontline service provider?

Characteristics and service use of homeless veterans and nonveterans residing in a low-demand emergency shelter.

Initial attributable cost and economic burden of clinically-relevant differentiated thyroid cancer: A health care service provider perspective.

Health provider perspectives on mental health service provision for Chinese people living in Christchurch, New Zealand.

Health and health needs of homeless and runaway youth. A position paper of the Society for Adolescent Medicine.

Coordination of care in the Chinese health care systems: a gap analysis of service delivery from a provider perspective.

Mental health and social service needs for mental health service users in Japan: a cross-sectional survey of client- and staff-perceived needs.

The management of health care service quality. A physician perspective.

The perceptions of homeless people regarding their healthcare needs and experiences of receiving health care.

Multiply disadvantaged: Health and service utilisation factors faced by homeless injecting drug consumers in Australia.

Health behaviors and health risks among homeless males in Utah.

The Flexible Care Service: a third-sector service for older people with mental health needs.

Current issues in the U.S. mental health service system--a community health perspective.

AIDS: a review from a health service perspective.

Smoking policy change at a homeless shelter: attitudes and effects.

Mental health service use among African-American emerging adults, by provider type and recency of use.

Mental health service and provider preference among American Indians with type 2 diabetes.

Variation in mental health service use among U.S. Latinos by place of origin and service provider type.

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