Outreach-based clinical pharmacist prescribing input into the healthcare of people experiencing homelessness: a qualitative investigation

Abstract Background Severely and multiply disadvantaged members of the homeless population are disproportionately vulnerable to exceptionally high levels of multi-morbidity and premature death. Given widespread calls for the development of interventions that might improve the uptake and effectiveness of healthcare for this population, this study investigated patient and other stakeholder perspectives regarding an outreach service, delivered by prescribing pharmacists in collaboration with a local voluntary sector provider, within homelessness services and on the street in Glasgow (UK). Methods The qualitative study involved semi-structured face-to-face interviews with 40 purposively sampled individuals with current or recent experience of homelessness (32 of whom had direct experience of the service and 8 of whom did not), all (n = 4) staff involved in frontline delivery of the service, and 10 representatives of stakeholder agencies working in partnership with the service and/or with the same client group. Pseudonymised verbatim interview transcriptions were analysed systematically via thematic and framework analysis. Results The service was effective at case finding and engaging with patients who were reluctant to utilise or physically unable to access existing (mainstream or specialist ‘homeless’) healthcare provision. It helped patients overcome many of the barriers that homeless people commonly face when attempting to access healthcare, enabled immediate diagnosis and prescription of medication, and catalysed and capitalised on windows of opportunity when patients were motivated to address healthcare needs. A number of improvements in health outcomes, including but not limited to medication adherence, were also reported. Conclusions A proactive, informal, flexible, holistic and person-centred outreach service delivered within homelessness service settings and on the street can act as a valuable bridge to both primary and secondary healthcare for people experiencing homelessness who would otherwise ‘fall through the gaps’ of provision. Prescribing pharmacist input coupled with third sector involvement into healthcare for this vulnerable population allows for the prompt treatment of and/or prescription for a range of conditions, and offers substantial potential for improving health-related outcomes.

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Multimorbidity and emergency department visits by a homeless population: a database study in specialist general practice

British Journal of General Practice ◽

10.3399/bjgp19x704609 ◽

2019 ◽

Vol 69 (685) ◽

pp. e515-e525 ◽

Cited By ~ 16

Author(s):

Matthew Bowen ◽

Sarah Marwick ◽

Tom Marshall ◽

Karen Saunders ◽

Sarah Burwood ◽

...

Keyword(s):

Emergency Department ◽

Hepatitis C ◽

General Population ◽

Alcohol Dependence ◽

Homeless People ◽

Multidisciplinary Care ◽

Emergency Department Visits ◽

Homeless Population ◽

Healthcare Needs ◽

Primary Healthcare Centre

BackgroundEstimating healthcare needs of the homeless is associated with challenges in identifying the eligible population.AimTo explore the demographic characteristics, disease prevalence, multimorbidity, and emergency department visits of the homeless population.Design and settingEMIS electronic database of patient medical records and Quality and Outcomes Framework (QOF) data of all 928 patients registered with a major specialist homeless primary healthcare centre based in the West Midlands in England, from the period of October 2016 to 11 October 2017.MethodPrevalence data on 21 health conditions, multimorbidity, and visits to emergency departments were explored and compared with the general population datasets.ResultsMost homeless people identified were male (89.5%), with a mean age of 38.3 (SD = 11.5) years, and of white British origin (22.1%). Prevalence of substance (13.5%) and alcohol dependence (21.3%), hepatitis C (6.3%), and multimorbidity (21.3%) were markedly higher than in the general population. A third (32.5%) had visited the emergency department in the preceding 12 months. Emergency department visits were associated with a patient history of substance (odds ratio [OR] = 2.69) and alcohol dependence (OR = 3.14).ConclusionA high prevalence of substance and alcohol dependence, and hepatitis C, exists among the homeless population. Their emergency department visit rate is 60 times that of the general population and the extent of multimorbidity, despite their lower mean age, is comparable with that of 60–69-year-olds in the general population. Because of multimorbidity, homeless people are at risk of fragmentation of care. Diversification of services under one roof, preventive services, and multidisciplinary care are imperative.

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Complex health service needs for people who are homeless

Australian Health Review ◽

10.1071/ah10967 ◽

2011 ◽

Vol 35 (4) ◽

pp. 480 ◽

Cited By ~ 16

Author(s):

Gaye Moore ◽

Elizabeth Manias ◽

Marie Frances Gerdtz

Keyword(s):

Emergency Department ◽

Health Service ◽

Service Providers ◽

Homeless People ◽

Complex Nature ◽

Service Needs ◽

Hospital Services ◽

Framework Analysis ◽

Care Needs ◽

Healthcare Needs

Background. Homeless people face many challenges in accessing and utilising health services to obtain psychosocial supports offered in hospital and community settings. The complex nature of health issues is compounded by lack of accessibility to services and lack of appropriate and safe housing. Objective. To examine the perceptions and experiences of homeless people in relation to their health service needs as well as those of service providers involved with their care. Design. A purposive sampling approach was undertaken with a thematic framework analysis of semi-structured interviews. Participants. Interviews were undertaken with 20 homeless people who accessed the emergency department in an acute hospital in Melbourne, Australia and 27 service providers involved in hospital and community care. Results. Six key themes were identified from interviews: complexity of care needs, respect for homeless people and co-workers, engagement as a key strategy in continued care, lack of after-hour services, lack of appropriate accommodation and complexity of services. Conclusions. Findings revealed the complex and diverse nature of health concerns in homeless people. The demand on hospital services continues to increase and unless government policies take into consideration the psychosocial demands of the communities most vulnerable people efforts to divert hospital demand will continue to fail. What is known about the topic? Homeless people have complex healthcare needs and are high users of emergency departments (EDs). The increasing demand on hospital services has led to a focus by the Australian State, Territory and Federal Governments on strategies to divert homeless people from presenting to the ED. What does this paper add? This paper gives an insight into the experiences of homeless people and health service provides who are directly involved in their care. This insight gives important focus on the health needs and service responses that currently exist and the ongoing challenges that face homeless people and the health professionals responding to those needs. What are the implications for practitioners? To adequately respond to the needs of homeless people safe and supportive accommodation is a crucial component of services required to try and break the cycle of representation to the emergency department. Individual engagement strategies with coordinated care between hospital and community are required to address the complex care needs and psychosocial issues.

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Care homes, their communities, and resilience in the face of the COVID-19 pandemic: interim findings from a qualitative study

BMC Geriatrics ◽

10.1186/s12877-021-02053-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Fiona Marshall ◽

Adam Gordon ◽

John R. F. Gladman ◽

Simon Bishop

Keyword(s):

Central Government ◽

Resource Constraints ◽

Care Delivery ◽

Care Home ◽

Third Sector ◽

Care Homes ◽

Framework Analysis ◽

Local Networks ◽

Care Home Staff ◽

East Midlands

Abstract Background From late February 2020, English care homes rapidly adapted their practices in response to the COVID-19 pandemic. In addition to accommodating new guidelines and policies, staff had to adjust to rapid reconfiguration of services external to the home that they would normally depend upon for support. This study examined the complex interdependencies of support as staff responded to COVID-19. The aim was to inform more effective responses to the ongoing pandemic, and to improve understanding of how to work with care home staff and organisations after the pandemic has passed. Methods Ten managers of registered care homes in the East Midlands of England were interviewed by videoconference or phone about their experiences of the crisis from a structured organisational perspective. Analysis used an adapted organisational framework analysis approach with a focus on social ties and interdependencies between organisations and individuals. Results Three key groups of interdependencies were identified: care processes and practice; resources; and governance. Care home staff had to deliver care in innovative ways, making high stakes decisions in circumstances defined by: fluid ties to organisations outside the care home; multiple, sometimes conflicting, sources of expertise and information; and a sense of deprioritisation by authorities. Organisational responses to the pandemic by central government resulted in resource constraints and additional work, and sometimes impaired the ability of staff and managers to make decisions. Local communities, including businesses, third-sector organisations and individuals, were key in helping care homes overcome challenges. Care homes, rather than competing, were found to work together to provide mutual support. Resilience in the system was a consequence of dedicated and resourceful staff using existing local networks, or forging new ones, to overcome barriers to care. Conclusions This study identified how interdependency between care home organisations, the surrounding community, and key statutory and non-statutory organisations beyond their locality, shaped decision making and care delivery during the pandemic. Recognising these interdependencies, and the expertise shown by care home managers and staff as they navigate them, is key to providing effective healthcare in care homes as the pandemic progresses, and as the sector recovers afterwards.

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“There is still a perception that homelessness is a housing problem”: devolution, homelessness and health in the UK

Housing Care and Support ◽

10.1108/hcs-06-2016-0003 ◽

2016 ◽

Vol 19 (2) ◽

pp. 33-44 ◽

Cited By ~ 2

Author(s):

Martin Whiteford ◽

Glenn Simpson

Keyword(s):

Qualitative Interviews ◽

Homeless People ◽

Small Sample ◽

Issue Salience ◽

Structured Interviews ◽

Healthcare Provision ◽

Policy And Practice ◽

Content Type ◽

The Uk ◽

Comparative Policy

Purpose The purpose of this paper is to provide an exploratory account of the links between devolution, homelessness and health in the UK. Specifically, it focusses on the policy context and governance structures that shape the systems of healthcare for homeless people in London, Scotland, Wales and Northern Ireland. Design/methodology/approach Empirically the paper draws on semi-structured interviews with a small sample of policy and practice actors from the devolved territories. Qualitative interviews were supplemented by a comparative policy analysis of the homelessness and health agenda within the devolved regions. Theoretically, it takes inspiration from Chaney’s concept of the “issue salience of homelessness” and explores the comparative character of healthcare as pertains to homeless people across the devolved territories. Findings The paper provides clear evidence of areas of divergence and convergence in policy and practice between the devolved regions. These features are shown to be strongly mediated by the interplay of two factors: first, the scope and scale of national and local homelessness prevention strategies; and second, intra-national variation in public health responses to homelessness. Originality/value The paper offers considerable insight from a comparative policy perspective into the nature of healthcare provision for homeless people in the devolved regions.

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Health and Access to Healthcare in Homeless People: Protocol for a Mixed-methods Study

10.21203/rs.3.rs-880066/v1 ◽

2021 ◽

Author(s):

Miguel A. Bedmar Pérez ◽

Miquel Bennasar-Veny ◽

Berta Artigas Lelong ◽

Francisca Salvà Mut ◽

Joan Pou Bordoy ◽

...

Keyword(s):

Mixed Methods ◽

Health Status ◽

Homeless People ◽

Premature Death ◽

Access To Healthcare ◽

Mixed Methods Study ◽

Poor Health ◽

Barriers And Facilitators ◽

Second Phase ◽

Structural Factors

Abstract BackgroundHomelessness is a more complex problem than the simple lack of a place to live. Homeless people (HP) often suffer from poor health and premature death due to their limited access healthcare, and are also deprived of basic human and social rights. The study protocol described here aims to evaluate the complex relationship between homelessness and health, and identify the barriers and facilitators that impact access to healthcare by HP.MethodsThis is a mixed-methods study that uses an explanatory sequential design. The first phase will consist of a cross-sectional study of 300 HP. Specific health questionnaires will be used to obtain information on health status, challenges during the COVID-19 pandemic, self-reported use of healthcare, diagnoses and pharmacologic treatments, substance abuse (DAST-10), diet quality (IASE), depression (PHQ-9), and human basic needs and social support (SSQ-6). The second phase will be a qualitative study of HP using the “life story” technique with purposive sampling. We will determine the effects of different personal, family, and structural factors on the life and health status of participants. The interviews will be structured and defined using Nussbaum's capability approach. DiscussionIt is well-known that HP experience poor health and premature death, but more information is needed about the influence of the different specific social determinants of these outcomes and about the barriers and facilitators that affect the access of HP to healthcare. The results of this mixed methods study will help to develop global health strategies that improve the health and access to healthcare in HP.

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Lithuania

10.1093/oso/9780198860525.003.0021 ◽

2021 ◽

pp. 456-472

Author(s):

Liubovė Murauskienė

Keyword(s):

Soviet Union ◽

Healthcare System ◽

Quality Care ◽

Healthcare Provision ◽

Universal System ◽

Health Politics ◽

Healthcare Needs ◽

The Soviet Union ◽

Out Of Pocket Payments ◽

Compulsory Health Insurance

This chapter examines health politics and the compulsory health insurance system in Lithuania and traces the development of its healthcare system. Since the country declared independence from the Soviet Union in 1990, Lithuanian health politics have revolved around restructuring and rationalizing the overcapacities of the inherited healthcare system, increasing levels of public finance to those sufficient to meet healthcare needs, and making good on the patient rights implied by a universal system. Despite those efforts, high out-of-pocket payments remain an obstacle to health solidarity, healthcare provision—which is predominantly public—is overly dependent on inpatient care, and public financing measured as a share of GDP remains low. As the chapter outlines, other issues include low levels of satisfaction with and trust in the health system and the persistence of informal payments to ensure quality care.

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Diabetes management interventions for homeless adults: a systematic review

International Journal of Public Health ◽

10.1007/s00038-020-01513-0 ◽

2020 ◽

Vol 65 (9) ◽

pp. 1773-1783

Author(s):

Janice Constance ◽

Joanne M. Lusher

Keyword(s):

Diabetes Management ◽

Diabetes Education ◽

Patient Empowerment ◽

Homeless People ◽

Models Of Care ◽

Homeless Population ◽

Homeless Adults ◽

Management Interventions ◽

Increased Risk ◽

Health Complications

Abstract Objectives Recent studies investigating diabetes show that inequalities to access appropriate care still persists. Whilst most of the general population are able to access a suitable quality of care, there are a number of groups who fail to receive the same standard. The objective of this review was to identify existing diabetes management interventions for homeless adults. Methods A literature search was conducted in February 2017, and repeated in September 2020. Results Of the 223 potentially relevant articles identified, only 26 were retrieved for detailed evaluation, and 6 met the inclusion criteria. Papers focusing on the management of diabetes in homeless people were included. The studies used interventions including diabetes education; medication support and supplies for blood monitoring; improvements in self-care behaviours; improvements in diabetes control; patient empowerment/engagement; and community engagement/partnerships. Conclusions Effective strategies for addressing the challenges and obstacles that the homeless population face, requires innovative, multi-sectored, flexible and well-coordinated models of care. Without appropriate support, these groups of people are prone to experience poor control of their diabetes; resulting in an increased risk of developing major health complications.

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Disaster Planning for Homeless Populations: Analysis and Recommendations for Communities

Prehospital and Disaster Medicine ◽

10.1017/s1049023x20000278 ◽

2020 ◽

Vol 35 (3) ◽

pp. 322-325 ◽

Cited By ~ 1

Author(s):

Stephen C. Morris

Keyword(s):

Emergency Preparedness ◽

Resource Constraints ◽

Homeless People ◽

Disaster Planning ◽

The United States ◽

Lessons Learned ◽

Homeless Population ◽

Special Populations ◽

Population Classification ◽

Mental And Physical Health

AbstractHomelessness is a growing problem, with perhaps greater than a 150 million homeless people globally. The global community has prioritized the problem, as eradicating homelessness is one of the United Nation’s sustainability goals of 2030. Homelessness is a variable entity with individual, population, cultural, and regional characteristics complicating emergency preparedness. Overall, there are many factors that make homeless individuals and populations more vulnerable to disasters. These include, but are not limited to: shelter concerns, transportation, acute and chronic financial and material resource constraints, mental and physical health concerns, violence, and substance abuse. As such, homeless population classification as a special or vulnerable population with regard to disaster planning is well-accepted. Much work has been done regarding best practices of accounting for and accommodating special populations in all aspects of disaster management. Utilizing what is understood of homeless populations and emergency management for special populations, a review of disaster planning with recommendations for communities was conducted. Much of the literature on this subject generates from urban homeless in the United States, but it is assumed that some lessons learned and guidance will be translatable to other communities and settings.

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Screening of problem gambling among a homeless population in Warsaw

Nordic Studies on Alcohol and Drugs ◽

10.1177/1455072519860291 ◽

2019 ◽

Vol 36 (6) ◽

pp. 542-555 ◽

Cited By ~ 1

Author(s):

Łukasz Wieczorek ◽

Jakub Stokwiszewski ◽

Justyna I Klingemann

Keyword(s):

Public Health ◽

General Population ◽

Problem Gambling ◽

Homeless People ◽

Severity Index ◽

Homeless Persons ◽

Health Concern ◽

Homeless Population ◽

Addictive Disorders ◽

Prevention Programmes

Background: While homelessness and problem gambling are both recognised as social and public health concerns and the prevalence of addictive disorders among homeless populations tends to be high. These questions have been studied predominantly independently. Aim: The aim of the study was to explore the co-occurrence of the two phenomena among the homeless population using shelters and night shelters in Warsaw, and, more specifically, to provide information about the forms and frequency of gambling in this homeless population. Method: Homeless persons ( N = 690) were interviewed in rehabilitation-shelters ( n = 17) and night-shelters ( n = 2) in Warsaw from November 2015 until January 2016. The core component of the questionnaire was a screening test (Problem Gambling Severity Index). In addition, data regarding the intensity of gambling and various types of games or settings were collected. Results: The prevalence of problem gambling in this population of homeless people was 11.3%, whereas the prevalence of problem gambling in the general population in Poland is much lower (0.7%). Similarly to the general population, the most prevalent gambling games in the homeless population were lotteries; however, homeless people gambled in lotteries almost three times more often compared to the general population. Conclusions: This is the first study examining the prevalence of problem gambling in the homeless population in Poland. The findings of the study suggest that problem gambling among the homeless is a significant social and public health concern. High rates of problem gambling in the homeless population show the need to identify and monitor this problem in shelters and consequently to provide easier access to gambling treatment or prevention programmes.

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Making the invisible visible: a place for utilizing activity theory within in situ simulation to drive healthcare organizational development?

Advances in Simulation ◽

10.1186/s41077-020-00148-8 ◽

2020 ◽

Vol 5 (1) ◽

Author(s):

Gerard J. Gormley ◽

Anu Kajamaa ◽

Richard L. Conn ◽

Sarah O’Hare

Keyword(s):

Organizational Development ◽

Activity Theory ◽

Health Care Systems ◽

System Level ◽

Main Body ◽

Healthcare Provision ◽

In Situ Simulation ◽

Healthcare Needs ◽

Care Systems

Abstract Background The healthcare needs of our societies are continual changing and evolving. In order to meet these needs, healthcare provision has to be dynamic and reactive to provide the highest standards of safe care. Therefore, there is a continual need to generate new evidence and implement it within healthcare contexts. In recent times, in situ simulation has proven to have been an important educational modality to accelerate individuals’ and teams’ skills and adaptability to deliver care in local contexts. However, due to the increasing complexity of healthcare, including in community settings, an expanded theoretical informed view of in situ simulation is needed as a form of education that can drive organizational as well as individual learning. Main body Cultural-historical activity theory (CHAT) provides us with analytical tools to recognize and analyse complex health care systems. Making visible the key elements of an in situ simulation process and their interconnections, CHAT facilitates development of a system-level view of needs of change. Conclusion In this paper, we theorize how CHAT could help guide in situ simulation processes—to generate greater insights beyond the specific simulation context and bring about meaningful transformation of an organizational activity.

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