Thesis PDF

Running head: BEST PRACTICES FOR HOMELESS HEALH CARE 1
EVIDENCED-BASED RECOMMENDATIONS FOR HEALTH CARE
PROFESSIONALS IN THE EMERGENCY DEPARTEMENT WORKING WITH THE
HOMELESS
By
HAILEY NICOLE PETTIS
____________________
A Thesis Submitted to The Honors College
In Partial Fulfillment of the Bachelors degree

With Honors in
Nursing
THE UNIVERSITY OF ARIZONA
MAY2017
Approved by:
____________________________
Patty Goldsmith, MS, RN, APHN-BC

College of Nursing Faculty
Running head: BEST PRACTICES FOR HOMELESS HEALH CARE 2
TABLE OF CONTENTS
Abstract3
Chapter 1..4
Background and History of the Homeless Population.4
Significance of the Problem.6
Important Terms Defined (Table 1) 9
Summary10
Chapter 211
Mental Health and Substance Abuse.11
Barriers for Homeless People Seeking Care......17
Homelessness and Emergency Department use....24
Conclusion.27
Chapter 329
Best Practice Recommendations for Providing Optimal Care to the Homeless....30
Best Practice Recommendation Components (Table 2) ...32
Levels of Evidence (Table 3) 36
Summary37
Chapter 438
Secure Recourses...38
Implementation Plan..39
Implementation of the Action Plan40
Evaluating the Outcomes...42
Reporting Outcomes to Stakeholders.43
Template for Executive Summary Using PET (Table 4) ..45
Summary46
References.47
BEST PRACTICES FOR HOMELESS HEALH CARE 3
Abstract
The purpose of this thesis is to establish best practice recommendations for health care
professionals (HCP) working in the emergency department (ED) and caring for homeless
patients. It is estimated that there are about 550,000 homeless people in the United States (HUD,
2016). Those that are homeless have a three to five times higher risk of mortality related to
illness than the non-homeless person (Weber, et al., 2013). The main barriers to health care are
transportation, cost, insurance, paperwork, knowledge about resources, communication issues,
respect, time restraints and mental illness and/or substance abuse. HCP must understand these
obstacles in order to provide optimal care for this vulnerable population. The recommendations
for providing care tailored to the homeless include screenings, consultation, advocacy, health
teaching, referral and follow-up and case management. The recommendations are theoretically
implemented into an ED in Tucson, Arizona through staff training and evaluation.

CHAPTER 1
Introduction
Statement of Purpose
The purpose of this thesis is to establish best practice recommendations for health care
professionals (HCP) working in the emergency department (ED) and caring for the homeless
population. Research from evidence based practice articles will aid in supporting the
recommendations. This paper will first address the past and current state of the homeless
population both the United States (US) and in Tucson, Arizona. This thesis will then discuss the
barriers homeless people face on a daily basis when seeking health care and how HCPs in the ED
assist in overcoming these barriers. The significance to health care, especially nursing, will also
be explored. Finally, this thesis will outline best practice recommendations in order to further
educate ED HCP on how to provide optimal health care to the homeless population. The research
has shown that the optimal area to implement these best practice recommendations is in the ED
due to the high usage from homeless people (Doran et al., 2013). This is because many homeless
people do not routinely seek primary care and wait for am emergency situation to seek care. In
addition, lack of insurance, lack of knowledge, and transportation barriers limit homeless access
to primary care; this will be further discussed in Chapters 2 and 3. It is because of this high
demand in the ED that the recommendations will be implemented in this setting (Doran et al.,
2013).
Background and History of the Homeless Population
Social conditions over the past few centuries have influenced changes within the
homeless community. In the late 1600s, religion was of the upmost importance to citizens.
People believed that God would intervene and bestow upon them supplies required for survival if
they proved to be a good Christian (Fischer, 2011). Those who were homeless were seen to have
a moral flaw and would have to seek salvation within another town. Once a homeless person
made the trip to a different town, he or she would have to prove his or her worth to the towns
fathers before being welcomed into the community (Fischer, 2011).
The next major period in the United States (U.S.) that affected the homeless population
was the Industrial Revolution from the late 1700s to the early 1800s. Many citizens were
migrating to large cities to find work (Fischer, 2011). The economy was rapidly increasing which
lead to more jobs, a better standard of living, and a decrease in the percent of homeless
Americans (Fischer, 2011). However, the homeless population did not disappear. Those with
mental or physical disabilities were unable to find work. Widows were also rejected from many
of the available jobs (Fischer, 2011). In the 1850s, the first documented cases of homeless youth
were recorded as many parents or guardians could no longer provide for the children financially
(Fischer, 2011). The next period effecting homelessness was the Civil War. During this period,
morphine was used to treat pain from battle injuries. By the 1870s-1890s, citizens could purchase
morphine and heroin from many local stores (Fischer, 2011). After the war, many veterans and
civilians became addicted to the medications and others suffered from post-traumatic stress
disorder (PTSD); both led to an increase in homelessness. Terms that arose from this area were
hobo," tramp," and bum (Fischer, 2011).
In the early 1900s, race, culture, and religion contributed to poverty and those who were
homeless. In addition to these factors, natural disasters such as earthquakes, fires, and floods left
many people without a place to live (Fischer, 2011). In the 1930s, the crash of the stock market
led to the Great Depression and the number of homeless people on the streets spiked (DeGrace,
2011). It was estimated that in 1933, there were 1.5 million homeless people in the US (DeGrace,
2011). The Housing Act of 1949 and the Fair Housing Act in 1968 were passed to assist in
getting Americans into homes (Fischer, 2011). In the 1970s, the correlation between mental
illness and homelessness increased dramatically (Frontline, 2005). This was in part due to
deinstitutionalization. Beginning in 1955, Thorazine became available in mass quantities and
patients where being moved out of institutions (Frontline, 2005). Those who were severally
mentally ill where also moved out and parts or entire intuitions where then closed. Those that
were discharged were not ensured of follow up care; this lead to a mental health crisis on the
streets and in prisons (Frontline, 2005).
Significance of the Problem
According to the U.S. Department of Health and Human Services, a homeless individual
is defined as an individual who lacks housing (without regard to whether the individual is a
member of a family), including an individual whose primary residence during the night is a
supervised public or private facility (e.g., shelters) that provides temporary living
accommodations, and an individual who is a resident in transitional housing (National Health
Care for the Homeless Council, 2017). Homelessness has a broad definition that can be broken
down into three subcategories which are chronic, transitional, and episodic homeless. These are
further defined in Table 1. It was estimated that during a single night in January of 2016 there
were 549,928 homeless people in the US (HUD, 2016). During 2015 there were approximately
2,110 people experiencing homelessness in Tucson (DaRonco, 2014). Although homelessness is
decreasing across America, it is still estimated that an adult has a 1 in 201 chance of being
homeless (Weber, Thompson, Schmiege, Heifer, & Farrell, 2013). Statistics have revealed that
minority groups who live in the US, have a higher risk of becoming homeless than developing
cancer (Weber et al., 2013). According to Weber et al. (2013), veterans have a greater risk of
becoming homeless than the general U.S. population.
Today, homelessness remains an epidemic. People who live in poverty are at a greater
risk of becoming homeless due to lack of sufficient finances and resources (National Coalition
for the Homeless, 2016). In 2015, the US Department of Housing and Urban Development
(HUD, 2016) released statistics on the current state of homelessness in America. Among these
statistics was an estimated 549,928 homeless people, with 65% of these individuals living alone,
while the other 35% represent those in a homeless family. HUD (2016) also stated that of the
48,000 homeless veterans, males represent 92% of the population.
HCPs in the ED must provide care for those in need. The homeless population has a three
to five times higher risk of mortality due to illness than the average citizen (Weber, et al., 2013).
There are still multiple concerns among this population and one of the most prevailing concerns
is health care needs. Not having a permanent address, little access to transportation, and little
money to spend on health care can lead to declining health in the homeless population
(DaRonco, 2014). Due to the fact that many homeless people are living with mental disorders
and other health concerns, the population requires an increased level of care to have their health
care requirements met (Currie, Patterson, Moniruzzaman, McCandles, & Somers, 2014).
Research has shown that an inadequate level of care has been provided to those experiencing
homelessness (Currie et al., 2014). Examples of inadequate care are poor accessibility, improper
discharge planning, a lack of substantial treatment options, and discrimination. Due to these
listed reasons, many homeless people do not seek primary care and only utilize emergency
services in times of extreme illness or injury (Currie et al., 2014). The ED has become a
substitute for primary care for many homeless people (Hunter et al., 2015). It is imperative that
ED employees are aware of best practices for homeless health care in order to optimize care for
this population.
There are many health disparities among the homeless population. Approximately 50% of
those who are homeless also have a mental illness diagnosis (Bharel et al., 2011). Forty-two
percent of homeless people reported having at least one symptom of depression (Bharel et al.,
2011). In addition, homeless people with a mental health diagnosis do not routinely seek out
proper treatment, which leads to worsening of the mental illness along with worsening of co-
morbidities (Chrystal et al., 2015). When homeless people with mental illness do seek out care,
they often have trouble adhering to medications, follow up appointments, and/or plans of care.
Sequentially, this population often turns to drugs or substance abuse to control their symptoms
(Burda, Haack, Duarte, & Alemi, 2011). According to Burda et al. (2011), 23% of homeless
patients who present with psychiatric disorders admit to substance abuse. In another study by
Bharel et al. (2011), the researchers found that approximately 70% of all homeless people abuse
alcohol and/or drugs. Homelessness increases the risk of non-adherence to medication regimes
for people with mental illness. It is estimated that 22% of homeless people do not properly take
their medication two days after a clinic visit (Burda et al., 2011). Other health disparities include
cardiovascular disease, in which only 17% of homeless people report having proper treatment for
their condition (Bharel et al., 2011). Poor living conditions lead to a higher prevalence of
infectious diseases with up to 45% of homeless persons having Hepatitis C and a HIV rates
seven times that of the general population (Bharel et al., 2011). Considering the major health
disparities for this population, it is imperative that HCP are aware of these conditions and treat
them appropriately.
Important Terms Defined
Table 1.
Types of homelessness
Term Definition
A person who had been homeless for an

extended amount of time. These people are
Chronic Homelessness
usually unemployed, use shelters on a long
term basis, and often have a disability.
Homeless individuals that enter the shelter

system for a short period. These people tend to
Transitional Homelessness
be younger and are homeless due to a
catastrophic event.
Those who transition in and out of

homelessness. This population tends to be
Episodic Homelessness
young and most experience medical, mental
health, and substance abuse problems.
Adapted from National Coalition for the Homeless. (2016). Homelessness in America.
Retrieved from http://nationalhomeless.org/about-homelessness/.
Summary
Homelessness is an epidemic across America. The state of homelessness has varied over
the centuries from a belief in a higher power to the Great Depression to deinstitutionalization.
Today homelessness revolves around barriers to care, a high incidence of health disparities, and a
general lack of knowledge about primary care. This leads to a lower use of primary care and a
higher incidence of emergency care. The purpose of this thesis is to describe best practice
recommendations for HCP working in the ED and caring for the homeless by utilizing evidence-
based research. Although the number of homeless individuals is slowly decreasing, homelessness
is far from being eliminated in the U.S. Major health problems associated with homelessness are
mental health concerns, substance abuse, and undertreated disease processes. By identifying
recommendations for caring for the homeless in the ED, this population will receive higher
quality health care along with appropriate referrals to needed care.

CHAPTER 2
Review of Literature
This review of literature addresses barriers to health care for people experiencing
homelessness, their impact on the population, and interventions that have been effective in
addressing barriers. The following research articles cover mental health, substance abuse,
physical barriers to care, and emergency department use and their effects on homeless health
care. For this thesis, the search engines that were utilized were EBSCO and PubMed. Keywords
to locate information included homeless with subheadings of health care and access to.
The 15 articles reviewed included two quasi-experimental studies, one longitudinal, one
correlational, three cross-sectional studies, two randomized control trials, one narrative synthesis,
one collaborative study, one-mixed methods review, one phenomenological approach, one
systematic review, one prospective study, and one qualitative study. The study findings will be
utilized to create best practice recommendations.
Mental Health and Substance Abuse
Large portions of homeless people are diagnosed with mental health conditions and/or
have reported substance abuse, along with alcohol consumption. This section reviews seven
evidenced-based articles that highlight the impact of mental health and substance abuse on the
homeless population. The research includes possible ways to best provide care for this
population.
Burda et al. (2012) conducted a quasi-experimental, prospective pilot study to evaluate
the possibility of monitoring medication adherence of homeless people with a psychiatric
diagnosis through a cell phone reminder intervention. The researchers had a sample size of ten
participants that were monitored over a span of 30 days. During each of the 30 experimental
days, an electronic survey was administered to the participants via a provided cell phone. Burda
et al. (2012) utilized Voxeos Interactive Voice Response systems to administer the surveys.
Results from the study revealed that participants who were reached conveyed they had taken
their medication 100% of the time and were taking the medication as prescribed (Burda et al.,
2011). After data collection, the researchers performed exit interviews in which two questions
were asked: What were your general impressions of the study? and What did you like or not
like? (Burda et al., 2012). The researchers concluded that the use of cells phones greatly
assisted with medication adherence and participants enjoyed using the cells phone to contact
family members (Burda et al., 2012). Burda et al. (2012) found the use of cell phones for
medication adherence for homeless with mental health concerns to be effective as participants
were reached on 93% of those days. A strength of the study was that no participants dropped out,
providing the researchers with sound results. Limitations of the study were a small sample size,
the sample was 80% men, and results were collected by self-reporting which could have led to
false data.
Currie et al. (2014) conducted a longitudinal study with two randomized control trials to
analyze the association between the use of health care and indicators of need among homeless
persons. The study focused on a homeless population with a mental health diagnosis. The study
recruited 497 participants that were randomly assigned to one of five groups, which consisted of
approximately 100 participants each. Baseline data was collected from interviews before the start
of the study. Results revealed that one month prior to the study, 49% of participants stated a HCP
had seen them and 27% reported having visited a psychiatrist (Currie et al., 2014). According to
Currie et al. (2014), 53% of the population had been hospitalized due to mental illness two or
more times within five years prior to the study and 12% reported a hospital stay longer than six
months (Currie et al., 2014). When assessing primary care needs, Currie et al. (2014) noted 79%
of the participants reported a low use of services (<3 visits) and 21% stated a high use of care
(>3 visits). Examining specialized care, 88% of participants had a low use of services and 12%
reported a high use of facilities (Currie et al., 2014). Currie et al. (2014) concluded that homeless
people with mental illness who presented with a greater need for health services accessed these
services significantly less than those with a lower need for care. The results provided evidence
that HCP are not adequately serving homeless individuals with a mental health diagnosis (Currie
et al., 2014). Insufficient involvement within the community was attributed to the worsening of
the health status of mentally ill homeless people, which leads to an increase in emergency service
use (Currie et al., 2014). Limitations of the study included a larger proportion of men than
women in the study and the correlational nature of the research makes the results difficult to
generalize. Strengths of this article were a large sample size and a high response rate from the
participants.
Chrystal et al. (2015) designed a correlational study to educate HCPs about predictors of
favorable primary care experiences from the homeless person with a mental health diagnosis.
The sample encompassed 366 randomly selected participants. The Primary Care Quality-
Homeless (PCQ-H) questionnaire was used to collect and assess data. The overall perception of
primary care via the sample was the dependent variable in this study. Data revealed that the
mean PCQ-H score for the sample as a whole was 3.13 on a 4-point Likert Scale (Chrystal et al.,
2015). The research concluded that the significant factors that increased positive experiences in
primary care are including a site offering services tailored to the homeless, allowing the
homeless to select a provider, and the housing status of the homeless person (Chrystal et al.,
2015). Chronically homeless and transient homeless persons were more likely to report negative
perceptions of primary care experiences (Chrystal et al., 2015). Those who had more severe
mental illness were also associated with reporting a poorer health care experience (Chrystal et
al., 2015). The overarching conclusion set forth by Chrystal et al. (2015) was that providing a
primary care service tailored to the homeless population led to a more positive experience of
those who are homeless and diagnosed with a mental health conditions. A limitation of the study
included a large portion of men in the sample. Strengths for the article were a large sample size
and the results were congruent with similar research.
Savage, Lindsell, Gillespie, Lee, and Corbin (2008) conducted a quasi-experimental pre-
post pilot study utilizing nurse-managed clinics. The purpose of this study was to assess the
homeless perspective of nursing interventions that aimed to better health outcomes. The
researchers hypothesized that nursing interventions would improve homeless mental health
status, reduces substance abuse, reduce emergency room visits, assist in making health care more
available, and provide homeless patients with a more satisfying clinic visit. Participants were
selected from a nurse-managed clinic and interviewed. A nursing intervention of an assessment,
health education, and referral for treatment was then conducted. One hundred twelve homeless
people participated in the study. Results showed a significant improvement in mental health and
vitality among homeless individuals (Savage et al., 2008). The posttest also revealed the mean
scores for physical health and social functioning improved (Savage et al., 2008). After the
intervention, the average score for assessed pain decreased (Savage et al., 2008). According to
Savage et al. (2008), the participants reported a significant improvement in perceived availability
and quality of care of health services. The researchers were able to conclude that the results from
the nursing intervention suggested a positive outcome on the mental health status and substance
abuse of homeless people (Savage et al., 2008). Strengths of the study were a large sample size
and the results concluded that testing nursing interventions was a feasible design. Limitations of
the study included self-reporting, no control group, and the results were difficult to generalize
due to the nature of the studys design.
OBrien et al. (2015) conducted a cross-sectional study in order to examine the
relationship among drug use, health, and use of health services among a homeless population in
Dublin. The researchers recruited 105 participants and provided them with a questionnaire that
aimed to assess reasons for homelessness, health, substance abuse, and use of health care
services. After analyzing the surveys, the results revealed that approximately one third of the
sample admitted to drug use and the most used illegal substance was heroin (OBrien et al.,
2015). The study reported that those who used drugs were less likely to make regular visits to
specialty care facilities, such as the dentist (OBrien et al., 2015). OBrien et al. (2015) attributed
this lack of attendance to cost issues, less accessibility, and reluctance to be seen by a stranger.
The results suggested that drug users were five time more likely to have multi-morbidities than
non-drug users (OBrien et al., 2015). The current drug users who were surveyed had a perceived
quality of life that was lower than non-drug users (OBrien et al., 2015). Limitations of the study
were more males than females were sampled and a convenience sample was used which could
lead to bias. A strength of the study was an adequate sample size.
Tomita and Herman (2015) completed a randomized control trial to contribute to current
research on how critical time interventions (CTI) influenced homeless people with mental health
diagnosis. The goal of the study was to prevent re-hospitalization after discharge from either a
floor unit or a psychiatric unit. Of the 150 participants, half were randomly assigned to a usual
service only (USO) group and half were randomly assigned to the CTI group. The researchers
then followed the participants over a span of 18 months post discharge. The interventions on the
CTI group included a referral to standard services, support in adjusting to community life,
community resources, and long-term support groups. The results from the study revealed that the
CTI group had a decrease in rehospitalization and homelessness (Tomita & Herman, 2015). At
the 18 month follow up, the CTI group presented with a greater perception of ease to care access
than the USO group (Tomita & Herman, 2015). The researchers concluded that those in the CTI
group had better access to care and were more likely to remain in the care of one social worker
and look to them for a means of support (Tomita & Herman, 2015). A strength of the study was a
large sample size. A limitation of this article included more males than females.
Levin et al. (2014) designed a cross-sectional analysis to compare attitudes towards
medication adherence and reasons for non-adherence of those with mental illness. The study
assessed three different cohorts to ascertain if there was a difference in medication adherence
among those with a mental health diagnosis. The first group had 43 participants with a bipolar
disorder and who were treated in a community health setting, the second cohort was constructed
from 43 participants diagnosed with bipolar disorder and who were taking atypical
antipsychotics, and the third group consisted of 30 participants with schizophrenia or a
schizoaffective disorder who reported being homeless within one year of the study. The
researchers utilized three tools to assess the attitudes towards medication adherence. These tools
included the Attitudes toward Mood Stabilizers Questionnaire (AMSQ), the Rating of
Medication Influence (ROMI), and the Drug Attitude Inventory (DAI). These tools were utilized
both pre and post intervention on each group. Interventions were comprised of four possible
modules: psychoeducation, medication routines, communication with providers, and substance
abuse. Baseline scores directed the interventions. The results discussed in this review of
literature will focus on cohort three, due to its relation to the homeless population. Results were
collected and analyzed to reveal that the modules led to improved medication adherence in all
three groups (Levin et al., 2014). Factors that were found to increase medication non-adherence
across the three cohorts were age and education (Levin et al., 2014). Analyzing the third group,
Levin et al. (2014) concluded that homelessness was strongly associated with medication non-
adherence. The researchers concluded that medication adherence interventions are successful for
a wide variety of mental illness patients and does not need to be specifically tailored to certain
conditions (Levin et al., 2014). The intervention was found to be effective with the homeless
population. Limitations of the study included a small sample size, self-reporting, and different
medications among the groups. A strength of the study was a low dropout rate.
Barriers for Homeless People Seeking Care
Multiple barriers to care arise when examining homeless health care. The six articles that
follow attempt to highlight those barriers. The information from this section will set the
foundation for the best practice recommendations in the third chapter of this thesis, along with
the other articles in this review of literature.
Weber, et al. (2013) conducted a collaborative, community based research project to
assess the incidence of chronic medical, psychiatric, and substance use among the homeless
population. Researchers obtained a convenience sample from a day shelter and surveyed 290
participants. The prevalence of disease burden, insurance availability, and perspective of access
to care was assessed using a survey. Results from the survey showed 43% of the sample reported
having been diagnosed with a serious/chronic health condition and 53% stated a diagnosis of a
mental health illness (Weber et al., 2013). Smoking was a common issue among the sample as
68% of the participants reported using cigarettes (Weber et al., 2013). When evaluating health
insurance, Weber et al. (2013) found that 23% of the sample had some form of health insurance
and that those with a more serious diagnosis were more likely to have insurance. When asked
their perception of care they received, 51% of the group who reported having access to health
care also reported being able to access these recourses when needed. (Weber et al., 2013). Other
than health insurance, the article concluded that other major barriers to care are social isolation,
prioritizing survival needs over health concerns, and emotional issues (Weber et al., 2013). There
is also a knowledge deficit among the homeless related to health care. A final finding was that
many homeless people did not access care because they are unaware of their eligibility for
insurance (Weber et al., 2013). Limitations of the study were more males than females in the
sample and self-reporting. A strength of the article was a large sample size.
Hauff and Turner (2014) designed a mixed-methods study to understand barriers to
homeless health care from the perspective of the chronically homeless and service providers. A
convenience sample of 10 local shelter staff and 14 health service providers was obtained. Semi-
structured interviews were utilized to obtain data. After the interviews were completed, a
descriptive content analysis was used to identify themes and patterns from the interviews. The
first theme of health problems and needs revealed that the homeless health needs were associated
with worsening acute and chronic conditions (Hauff & Turner, 2014). A majority of the shelter
staff members stated diabetes was the most common disease process (Hauff & Turner, 2014).
The HCP stated that for those who are homeless, health care is not a priority (Hauff & Turner,
2014). Due to the fact that homeless people do not routinely seek health care, there is a trust
barrier among HCP and the homeless (Hauff & Turner, 2014). Under the barriers to care theme,
shelter staff reported lack of supplies and nutrition for diabetic patients (Hauff & Turner, 2014).
The staff also reported a high incidence of unreported sexual assault in women, which led to
difficulty referring them to appropriate care (Hauff & Turner, 2014). The researchers then
identified a medical respite and support service needs theme, which stated medical respite
programs were needed among the homeless population (Hauff & Turner, 2014). The staff
reported that a lack of health care professionals in the shelter led to a lack of self care among the
homeless. For example, those with diabetes would neglect blood glucose monitoring and insulin
injections due to a lack of resources for diabetic education (Hauff & Turner, 2014). This is
attributed to a lack of education and respite programs. The shelter staff members stressed the
need for transitional care for those who are not sick enough to be inpatients but too sick to be
living on the streets (Hauff & Turner, 2014). The HCP agreed that a respite program is necessary
to connect homeless patients with services aimed to assist in recovery, medication
administration, and provide needed education (Hauff & Turner, 2014). A theme of discharge
planning was evaluated from the HCP perspective. Hauff and Turner (2014) revealed that HCPs
know there is limited access to medical care on the street, but still discharge ill homeless patients
(Hauff & Turner, 2014). Hauff & Turner (2014) concluded that barriers to health care included
lack of transportation, health insurance, a permanent address, lack of trust in HCP, mental
illness, and substance abuse. A limitation of the study was a small sample size; in order to
generalize the results, the researchers would need to gather more data in multiple areas. A
strength of the study was that it continues to add to the growing body of homeless health care
research.
Wise and Phillips (2013) designed a study to gain an understanding of the homeless
experience in the health care system. The researchers utilized a phenomenological approach and
interviewed 11 homeless participants. After the interviews, four themes were analyzed. The first
theme of same/different described an us/them mentality in which homeless people reported
feeling judged by their clothes, smell, and status when in a health care setting (Wise & Phillips,
2013). The second theme was labeled fair/unfair. The homeless people in the interviews stated
being treated unfairly with longer wait times, unmerited arrests, and groundless accusations
(Wise & Phillips, 2013). Many homeless people also stated a feeling that doctors and nurses did
not care about their health (Wise & Phillips, 2013). The third theme of freedom/barriers
highlighted the unfair bureaucracy, increased paperwork, and physical barriers that prevent the
population from receiving adequate health care (Wise & Phillips, 2013). Wise and Phillips
(2013) concluded that because the homeless had no way to pay for their care, proper treatment
was not administered. Analyzing the final theme of choice/no choice, the homeless sample
revealed that the choice for survival needs was greater than the choice to seek health care (Wise
& Phillips, 2013). Due to this fact, many homeless people wait for an emergency to seek care,
leading to the ED becoming the primary care for the homeless population (Wise & Phillips,
2013). A limitation of the study was a small sample size. Strengths of the study were the use of
bracketing to reduce bias and the article highlighted the importance of fair treatment among the
homeless population within the health care system.
Kertesz et al. (2014) created a cross-sectional, community-based survey to assess the
unmet need for health care and analyze the accessibility of health agencies among the homeless
population. A random sample was collected from four shelters in Birmingham, AL with 200
participants. The participants were then given a survey that measured access to specialty health
services (general health, specialty care, mental health, dental, and prescription medicine). The
survey then assesses if the types of care were easy or hard to access; if a service was difficult
to access, a follow up question of what made that service difficult to access was asked. Results
stated that the most prevailing health concerns among the sample were addiction (54%), mental
illness (46%), hypertension (46%), and diabetes (21%) (Kertesz et al., 2014). Less than 20% of
the sample reported having perceived themselves as being in good health and over half of the
sample reported an unmet need for general health care (Kertesz et al., 2014). When care was
difficult to access, the most common barriers were the inability to pay, lack of transportation,
lack of education on where to obtain care, inconvenient hours, and excessive waiting times to be
seen (Kertesz et al., 2014). The survey concluded that the most prevalent place the homeless
accessed care was in health care for the homeless centers (51%), free clinics (31%), and hospital
clinics (23%); many participants also reported ED use (Kertesz et al., 2014). Among the places
where the homeless access care, the free clinics were described as the easiest to access and the
ED was difficult to obtain care (Kertesz et al., 2014). Limitations of the study included self-
reporting and the survey did not assess physical or sexual assault cases. Strengths of the study
were a large sample size and an almost equal proportion of men and women. The study used a
random sample, which increased the validity of the article.
OToole, Johnson, Borgia, and Rose (2015) designed a two-by-two randomized control
trial of homeless veterans to increase the health-seeking behaviors of this population. The study
consisted of 185 homeless veterans that were recruited from a VA health center. The participants
were randomly assigned to one of three groups: The Personal Health Assessment/Brief
Intervention (PHA/BI), the Clinical Orientation Arm (CO), or the Usual Care (UC) group. The
PHA/BI arm of the study consisted of a nurse-led interview, an intervention based on the
interview, and a physical exam. Within the CO arm, participants were taken to a clinic by a RN
and shown the check-in desk, the process for being seen, and additional resources available at the
visited clinic. The UC group was assigned a social worker to assess the participants homeless
history and social needs, and to provide written or verbal descriptions of clinical services.
Participants were interviewed at baseline, a 4 week follow up interview, and a 6-month

interview. OToole et al. concluded that 77.3% of the PHA/BI plus CO group visited primary
care within the first 4 weeks post intervention and 88.7% accessed primary care by the 6 month
follow up (2015). The CO only group had 50% of the participants access primary care within 4
weeks and 80% visited a primary care office by the 6-month interview (OToole et al., 2015).
Examining the PHA/BI only group, 41% of the participants accessed primary care before the 4-
week interview and 56.4% visited primary care by 6 months after the intervention (OToole et
al., 2015). The result from the study concluded that the UC group had the lowest percent of
participants seek primary care (OToole et al., 2015). Thirty percent of the UC group received
primary care by the 4-month interview and 37.1% sought out primary care by 6-months
(OToole et al., 2015). The researchers were able to conclude that interventions among homeless
veterans were effective in getting the population to seek out primary care (OToole et al., 2015).
OToole et al. (2015) also examined aspects of clinics that enabled access to care which included
affordability, ease of access, and transportation. Limitations of the study included only utilizing
one geographical area and only homeless veterans were interviewed. If more locations were
utilized and different groups of homeless people were interviewed, the results would be more
generalizable. Strengths of the study include a low dropout rate and a large sample size.
White and Newman (2015) conducted a quasi-systematic review of twelve articles to
identify barriers and facilitators for primary care among the homeless and provide
recommendations for HCPs who provide care to this population. White and Newman located the
articles through PubMed, CINAHL, and PsycINFO (2015). The articles were restricted to the
United States and went through a rigorous screening process. The researchers defined
characteristics of health delivery systems that improved homeless access to primary care. White
and Newman (2015)concluded that homeless-specific primary care delivery systems that
provided multiple services in one location increased access to care for homeless patients. Patients
who visited tailored clinics reported higher satisfaction scores than those who visited a non-
tailored clinic (White & Newman, 2015). In addition, homeless patients were more likely to visit
and receive regular care through the tailored clinics (White & Newman, 2015). Diseases such as
hypertension, diabetes, and hyperlipidemia were seen most often and these chronic conditions
improved through the care of tailored clinics which lead to a decrease in ED visits (White &
Newman, 2015). The researchers then examined barriers and facilitating characteristics
associated with homeless persons when obtaining health care. Predisposing barriers included
chronic homelessness, mental illness, and psychological distress (White & Newman, 2015).
White and Newman also discovered that sociodemographic characteristics could be considered a
predisposing barrier. Males, Hispanics, adults younger than 41 years, those without a high school
degree, and nonveterans are least likely to report a usual source of care (White & Newman,
2015). Predisposing facilitators for having usual care were being recently homeless, being
female, being older than 41 years, or being a veteran (White & Newman, 2015). Enabling
barriers to primary care included competing priorities such as difficulty locating food, shelter,
clothing, bathing, and/or a place to use the restroom (White & Newman, 2015). When basic
needs are not met, health care needs are less likely to be satisfied (White & Newman, 2015). The
researchers found that multiple articles concluded that the inability to pay for medical care was
the primary barrier (White & Newman, 2015). Enabling facilitators that allowed homeless people
to obtain care were health insurance coverage, having a regular source of care, having basic
needs met, transportation, serious mental illness, or having a greater need for medical care
(White & Newman, 2015). White and Newman (2015) concluded that individuals with one or
more comorbid conditions were more likely to report barriers to care than those without
comorbidities. For the utilization of health services category, White and Newman (2015)
reported that free clinics proved to be the most accessible type of health care and emergency
departments were the most restrictive. The last aspect of the articles the researchers identified
was consumer satisfaction. White and Newman found that homeless patients wanted HCP who
were committed and engaged with the patients and their care (2015). Homeless patients were
more satisfied when the health care staff demonstrated empathy, sensitivity, and acceptance
while not being concerned with stereotyping or prejudice (White & Newman, 2015). Limitations
to the study were redundant sampling and the fact that many studies only surveyed homeless
veterans. The main strength of the review was that the researchers were able to draw accurate
conclusions about the barriers and facilitators of primary care access among the homeless.
Homelessness and Emergency Department Use
Due to multiple barriers to health care, the homeless population has a low primary care
attendance rate. By not seeking primary care, many homeless people wait until an emergency to
seek care. The following two articles discuss homeless care in the ED and stress the importance
of primary care.
Hunter et al. (2015) designed a prospective cohort study to determine the prevalence of,
reasons for, and factors associated with medication non-adherence among the homeless
population in three cities in Canada. The study also examined the association between
medication non-adherence and emergency department use after a one-year follow up interview.
The study consisted of 595 homeless and 596 vulnerably housed participants. Data was collected
through a 60 to 90-minute interview and a follow up interview 12 months after the first. The
Alcohol Use Disorder Identification Test (AUDIT) assessed alcohol abuse and drug abuse was
assessed with the Drug Abuse Screening Test (DAST). Seven hundred sixteen participants
reported taking prescription medication. Of this group, 26% reported medication non-adherence
(Hunter et al., 2015). Hunter et al. (2015) discovered that the most common reasons for
medication non-adherence were the prices, difficulties storing the medication, inability to take
medications as recommended, disliking side effects, and not believing in taking medication.
When comparing medication non-adherence to ED use, Hunter et al. (2015) stated that 18% of
those who reported non-adherence also reported visiting the ED grater then three at the 12 month
follow up. Those that were most likely to not take medications as prescribed were younger than
40 years, employed in the past 12 months, had a higher AUDIT risk score, and no access to a
primary care provider (Hunter et al., 2015). Other reasons for medication non-adherence were
housing status, lacking a safe place to store the medication, and having competing priorities
(Hunter et al., 2015). Limitations of the study included self-reporting and a lack of information
on certain medication that were prescribed to the participants. Self-reporting can lead to incorrect
information, which may create false data. Strengths of the study are a large sample size with a
small dropout rate. The results were also consistent with similar research providing validity to
this study.
Doran et al. (2013) conducted a qualitative study to gain an understanding of factors that
affect health care delivery to the homeless population in the ED. The researchers conducted
semi-structured interviews with ED physicians between two hospital residency programs.
Theoretical saturation for the sample was reached after the interviews with 23 participants. The
researchers used a random number generator to select physicians to decrease selection bias. Once
the interviews were completed, transcripts were reviewed line by line and coded. The themes of
the use of pattern recognition in identifying and treating patients who are homeless, variations
from standard ED care for patients who are homeless, and tensions in navigating the boundaries
of ED social care were recurrent. This first theme of pattern recognition to identify and treat
homeless patients revealed that many physicians determine the homeless status of patients based
on stereotypes or biases (Doran et al., 2013). Most physicians reported that they would not
routinely ask patients about their housing status (Doran et al., 2013). When homelessness was
assessed, many physicians reported a significant percent of this population was mentally ill or
struggled with substance abuse (Doran et al., 2013). Under the second theme, variations from
standard care for homeless patients, Doran et al. (2013) discovered that a homeless status
affected whether physicians would admit the patient to the hospital or discharge him or her from
the ED. Many participants of the study reported being more likely to admit homeless patients
then those who were not homeless with similar illnesses (Doran et al., 2013). Barriers to
appropriate care were also revealed. For example, many physicians stated they were more likely
to rush standard ED care in order to release the homeless client before the closure of a nearby
shelter (Doran et al., 2013). Other barriers included homeless susceptibility to infection and
secondary illness due to unsafe, unclean, and crowded living areas (Doran et al., 2013). The
barrier of communication was also identified, especially for intoxicated and mentally unstable
homeless patients (Doran et al., 2013). All of these barriers were exacerbated during busy times
in the ED (Doran et al., 2013). The final theme of tensions in navigating the boundaries of social
care highlighted the fact that physicians also have to take on the role of a social worker when
homeless persons present to the ED (Doran et al., 2013). Physicians in the study reported that
homeless patients present to the ED with medical needs along with shelter and food needs
(Doran et al., 2013). Participants reported that on cold winter nights they were very likely to
admit homeless persons to ED to allow them to have a place to sleep (Doran et al., 2013). The
subject of social work done voluntarily by physicians brought up tension by many participants.
Some physicians argue that social care was an integral aspect of ED care, while others stated that
spending time on social work distracted from time caring for critical patients (Doran et al.,
2013). Limitations of the study included the location of the sample and only interviewing
physicians who worked in one hospital system. If the sample was obtained from a rural ED and if
homeless patients were interviewed as well, the results could have differed. The study added new
information to the limited research about homeless care in the ED, which proved to be a strength
of the study.
Conclusion
The homeless population is not receiving proper health care across the United States. The
main barriers to care identified in this review of literature are: mental illness, substance abuse,
other emotional distress, health insurance issues and cost of care, paperwork, trust, respect, and
communication issues, competing basic survival needs, transportation, inconvenient hours and
waiting times, and knowledge deficits on part of population, shelter staff and HCP. The impact
of these barriers included medication non-adherence, poor control of mental and physical health
problems, use of emergency care rather than primary care, and dissatisfaction with care. The
literature review also highlighted the fact that homeless people have many competing priorities.
These priorities included locating shelter, purchasing food, having a place to shower, and
purchasing clothing. Many homeless people battle with drug and/or alcohol abuse and/or mental
illness. Interventions addressing barriers to care included programs tailored to the homeless
which addressed cost, medication adherence, health education, referrals for treatment, basic
survival needs, skilled assessment, health education, and care provided by knowledgeable,
caring, respectful HCP. The research reviewed will be utilized to create best practice
recommendations for HCP in the ED caring for homeless patients. The recommendations will be
detailed in Chapter 3. The goal of the recommendations will be to provide optimal health care to
the homeless in the ED to increase their overall quality of life.

CHAPTER 3
Best Practice Recommendations
The purpose of this thesis is to establish best practice recommendations for HCP working
in the ED and caring for the homeless population. This chapter will provide details on the
recommendations. All of the information was obtained from articles in the review of literature
from Chapter 2. The information provided will be aimed towards the education of HCP working
in the ED and caring for a homeless patient. Although not all HCP strictly work with the
homeless population, education on this vulnerable population is essential for a more holistic
approach to health care. Interventions addressed include screenings, consultation, advocacy,
health teaching and referral and follow-up. The topics that are included within the categories are
the promotion of medication adherence, cultural competence training for HCP, social service
needs, prevention of hospitalization, meeting health needs through a physical assessment, critical
time interventions performed by nurses, increasing accessibility of health services, education for
discharge and respite programs.
The literature reviewed in Chapter 3 provided insight on how to best care for patients that
are homeless. Through interventions and qualitative studies, the literature revealed that providing
care to the homeless is not strictly medical care but also considering the social needs of the
patient. Providing care to the homeless population begins with first identifying the patient as
homeless. Hospitals, clinics, and EDs should have a standardized tool to evaluate and document
the housing status of each patient (Doran et al., 2013). In identifying the patient as homeless,
care can be catered to their more specific needs. These needs include social care as well as health
care. Social care to take into consideration is transportation, shelter, food, clothing and hygiene
needs (Doran et al., 2013). Another key aspect that came from the review of literature is to treat
the homeless patient with the same respect and dignity as any other patient. This can be done by
not pre-judging or profiling the patient (Wise & Phillips, 2013). By making it known to the
patient that the health care team has a genuine concern for his or her health, the homeless patient
will gain a sense of respect and feel more comfortable in the heath care setting. This also assists
in promoting regular visits to clinics or primary care offices (Wise & Phillips, 2013). The last
major point assessed in the review of literature, is that the homeless population has competing
factors that take priority over seeking health care. With homelessness, people will seek out food,
shelter and other basic needs before seeking out health care (White & Newman, 2015). This is
further defined utilizing Maslows Hierarchy of Needs. According to the hierarchy, one will seek
food, clothing and shelter as a basic need for survival (Townsend, 2014). A person must first
meet his or her basic needs before moving to the next tier on the hierarchy of needs. It is
imperative for HCP to understand these concepts in order to provide care in a holistic manner.
Best Practice Recommendations for Providing Optimal Care to the Homeless
Best practice recommendations for care of the homeless in the ED are described in Table
2 to assist HCP in the ED provide optimal care to the homeless. The recommendations will
outline specifics to be included in the education tool. Many HCP have a misconception of the
homeless population due to their appearance, education level, and lack of hygiene. This leads to
care that does not always have the patients best interest in mind (Wise & Phillips, 2013).
Education sessions should be implemented to provide information on homeless people and to
eliminate bias that employees may contain. Many homeless people have stated that they do not
feel comfortable seeking out health care because they are treated unfairly. In addition, many
homeless people have difficulties with the paperwork, as they do not commonly fill out health
care forms (Wise & Phillips, 2013). For these reasons, among others, the homeless population
tends to underuse routine heath care services and overuse emergency services (Doran et al.
2013). The goal of this thesis is to provide best practice recommendations for HCP working with
homeless patients in the ED.

Table 2.
Best Practice Recommendations Components
In-Text Citation Level of

HCP Interventions Components to be Included
of Reference Evidence
- Screen for evidence of sexual
assault
- Screen all homeless patients
for common chronic diseases:
hypertension, diabetes, and
hyperlipidemia
- Screen the patients homeless
status: chronically, episodic, or
transitionally homeless and Hauff & Turner, Level VI
utilize a uniform 2014
documentation process
- Complete a full interview Kertesz et al., Level III
including health history and 2014
Screenings and
social history
Assessment
- Provide a complete head to toe White & Level V
physical assessment Newman, 2015
- Assess for worsening of acute
and chronic conditions Chrystal et al., Level III
- Assess about competing 2015
priorities: shelter, food,
clothing, and bathing
- Assess nutritional status
- Assess for barriers to care:
transportation, health
insurance, mental illness,
substance abuse, and insurance
status
- Consult case management

- Have at least one point of care
person in which the homeless
patient can rely on for health
care concerns (ie a case Tomita &
manager or PCP) Herman, 2015
- Consult medical specialists as Level II
needed based on assessment Kertesz et al.,
- Consult psychiatric/mental 2014
health services and substance Level III
Consultation
abuse services Doran et al.,
- Allow ample time to compete 2013 Level VI
assessment
- Consult community shelter OToole et al., Level II
and/or shelter providers 2015
- Minimize the number of
prescribed and over the
counter medications through
consultation with pharmacy
- Focus health teachings on:
- The importance of follow up
care and assist in scheduling
follow up visits
- Provide education on services
offered at the clinic, include
education on nonmedical Levin et al., Level VI
services (ie housing and jobs 2014
Health Teaching services)
- Provide in-depth education on Burda et al. Level III
medications and facilitate in (2012)
the storage of medications
- Educate homeless patients of
community resources targeting
homeless population.
- Provide patient information on
what to expect during ED visit
- Do not profile patient based on

clothing or bodily smell
- Monitor and expedite wait
times
- Minimize and assist with
paperwork
- Make it known that all
professionals in the clinic or
Wise & Phillips, Level VI
setting care about the homeless 2013
persons health and well-being
- Provide the same care for both Doran et al., Level VI
insured and uninsured 2013
Advocacy homeless patients when
Tomita & Level II
possible
Herman, 2015
- Assist with transportation from
ED to shelter as needed OToole et al., Level II
- Be aware and understanding of 2015
common homeless barriers to
communication such as: active
psychosis, alcohol
intoxication, and drug
intoxication
- Be prepared to discharge
homeless patient in a timely
manner as to provide time for
them to arrive at a shelter
before it closes
- Maintain a updated list of

community resources for the
homeless and refer as needed
- Provided personalized
discharge plans that focus on
areas that assist with
successful community
adjustment
- Refer to substance abuse and
mental health treatment
programs as needed
- Refer to clinics in homeless
centers or near shelters or near
public transportation
- Refer to primary care provider
or primary care clinic for Doran et al., Level VI
homeless if available in 2013
community
- Refer to free clinics that are Tomita & Level II
accessible Herman, 2015
- The program should connect
Referral and Follow-up homeless patients with Kertesz et al., Level III
resources that assist with 2014
recovery from illness or
surgery Hauff & Turner, Level VI
- Refer to psychosocial 2015
interventions that address
reasons for medical
nonadherence, which could
include: psychoeducation,
assistance with creating
medication routines, and
communication between
providers and substance abuse
interventions
- Refer to respite programs if
necessary and available
- Identify those who are too sick
to be on the streets but not sick
enough to be an inpatient as a
candidate for a respite program
Table 3.
Level of Evidence
Level of Evidence Description

Level I Evidence from a systematic review or meta-analysis of all relevant
RCTs (randomized controlled trial) or evidence-based clinical
practice guidelines based on systematic reviews of RCTs or three or
more RCTs of good quality that have similar results
Level II Evidence obtained from at least one well-designed RCT (e.g. large
multi-site RCT)
Level III Evidence obtained from well-designed controlled trials without
randomization (i.e. quasi-experimental)
Level IV Evidence from well-designed case-control or cohort studies.
Level V Evidence from systematic reviews of descriptive and qualitative
studies (meta-synthesis)
Level VI Evidence from a single descriptive or qualitative study.
Level VII Evidence from the opinion of authorities and/or reports of expert
committees
Adapted from Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based
nursing care guidelines: Medical-surgical interventions. (p. 7). St. Louis, MO: Mosby Elsevier.
Summary
Table 2 was created to inform HCP working in the ED on the best practices for homeless
health care. With a vulnerable population, such as the homeless, there are many stigmas present
that can lead to suboptimal care. By educating HCP, the goal of this thesis is to not only reduce
these stigmas but to assist in providing enhanced care to the homeless population that seeks care
in the ED. The recommendations are based on interventions such as screenings, consultation,
advocacy, health teaching and referral and follow-up. In Chapter 4, a theoretical implementation
of these interventions will be discussed.

CHAPTER 4
Implementation and Evaluation of Evidenced Based Recommendations
The fourth and final chapter of this thesis will focus on the theoretical implementation
and evaluation of the best practice recommendations for homeless health care in the ED as
detailed in Chapter 3. The chapter will follow guidelines set forth from the Johns Hopkins
Nursing Evidence-Based Practice Model (Dearholt & Dang, 2012). The beginning portion will
focus on the resources and support needed for implementation. The following section will
discuss the implementation action plan. This will include communication to those involved,
appointing leadership, and a pilot test of the recommendations. The third section will be the
evaluating of the implemented recommendations. The evaluation process and measurement of
outcomes will be reviewed in detail. The final section will be the dissemination of outcomes to
the stakeholders. For the purpose of this thesis the implementation and evaluation plan will be
theoretically discussed.
The research has suggested that an optimal area for implementation of a best practice
recommendations for homeless health care would be in the ED (Doran et al., 2013). As many
homeless people utilize the ED as their primary form of health care, HCP that work in the ED are
at a higher likelihood of serving this population (Doran et al., 2013). The best practice
recommendations will be implemented at an ED in Tucson. The recommendations will be
implemented through ongoing training of existing ED HCP. Evaluations will then be completed
to monitor the progress of the implementation.
Secure Resources
The first step to implement the homeless health care best practice recommendations
detailed in Chapter 3 is to secure support and resources (Dearholt & Dang, 2012). This will be
accomplished by bringing the topic to the attention of organizational leaders and department
stakeholders of the ED. The topic will first be discussed with the ED department head, the ED
nurse manager, and others involved in ED decision making. Once support is gained from this
group of leaders, attending physicians and charge nurses will be involved in the beginning
process. According to Dearholt and Dang (2012), a committee whose purpose is to discuss
means of implementation should be formed. The committee will be comprised of those who will
implement most of the recommendations. This includes the entire interdisciplinary team as a
whole. Once a committee is formed, the next phase is to determine the need for resources and to
estimate a budget (Dearholt & Dang, 2012). The committee will also establish roles for each of
the HCP team members. The theoretical resources that would be needed for this
recommendations include ongoing staff training, experts to conduct the training, space for the
staff training, a budget to pay employees for the training. In addition to training there would need
to be space and time for the committee to meet regularly and to evaluate progress of the
implementation. Finally, the recommendations would require technological personal to install a
section in the electronic charting system that screens each patient for homeless status. If it was
charted that the patient is homeless, the program would direct the HCP to other interventions to
best serve this population. Education on how to screen patients in the ED and what interventions
to follow with a positive screening, will also be included in the training.
Implementation Plan
After the recommendations have support and appropriate resources are gathered, the
committee would be tasked with creating a detailed implementation plan. The first step will
include securing a location to educate the staff on the best practice recommendations. Staff
training will be taught and evaluated by a committee member quarterly. There will be four
different times available to accommodate everyones schedule and the class will be mandatory
with hourly pay. The committee would also need to create a pre and posttest in order to evaluate
the effectiveness of the teaching. Then baseline data would need to be collected. This would be
done by surveying homeless patients in the ED. The survey will be conducted by a designated
member on the committee immediately prior to discharge from the ED. This will be a five point
Likert scale survey based on the patients perception of satisfaction of care received. The data
will be utilized to assess if the intervention was effective. Once staff has been educated and
baseline information has been collected and analyzed, the recommendations will be implemented
in the ED. Each patient will be screened for homelessness by the admitting nurse and appropriate
treatment will be utilized with a positive screening. Lastly, the implementation plan will include
ways to check that the recommendations are being implemented by ED staff. This would include
random audits that the HCP are aware will be happening. Audits will be completed by an
assigned committee member. Based on what the committee finds through audits and the general
consensus of the staff, the implementation of the recommendations will be altered on an as
needed basis. The ultimate goal will be to create a system in which the best practice
recommendations for homeless health care is implemented hospital-wide.
Implementation of the Action Plan
According to Dearholt and Dang (2012), the first step in actually implementing the action
plan is to make everyone who would be caring for the patient population aware of the
recommendations that will be utilized. In the case of the ED, all HCP have the potential to care
for a homeless patient, so the entire unit will be notified. A unit-wide email will be sent out to all
HCP with a basic overview of the purpose of the recommendations, as well as a list of times to
sign up for the staff training. A deadline to sign up will be initiated to assure compliance. In
addition, reminders will be verbally communicated on a regular basis. For example, it will be the
task of the charge nurse to remind the nurses on the unit to sign up for the staff training during
the pre-shift huddle. Fliers will also be placed in break rooms. During this time, the leader will
also be identified and available for information or supplies (Dearholt & Dang, 2012). The leader
in the case of this recommendations would be the head of the committee.
The first aspect of the training will be a pretest to gage the knowledge of homeless
education among the ED staff members. Topics that would be covered in the training are first
how to screen for homelessness. This includes differentiating between the three subcategories of
homelessness: chronic, transitional, and episodic (National Coalition for the Homeless, 2014).
The next portion of the training will include types of interventions that have proven to be
effective when caring for a homeless patient. There will be a total of six education topics that
follow the best practice recommendations from Chapter 3.
Medication adherence will be the first topic discussed. Staff will be able to collect a
medication history from the homeless patient and be able to optimize the medication being taken
by the patient. In addition, the importance of medication education will be greatly stressed
(Levin et al., 2014). The second topic will be on providing culturally competent care. Health care
professionals in the training will know the importance of providing effective care in a way that
does not discriminate against housing status or insurance availability (Wise & Phillips, 2013). If
the homeless patient is to be discharged from the hospital, staff will be educated on homeless
shelters in the area. The HCP will also be informed on ways to set up transportation, minimize
paperwork, and set up referrals on an as needed basis (Doran et al., 2013). Along with care
coordination and discharge planning, the staff will be educated on prevention of rehospitalization
and/or prevention of preventable subsequent ED visits. This will be done by providing

information on follow up care and emphasizing the importance of keeping appointments (Tomita
& Herman, 2015). The next topic will include routine screening and assessments of a homeless
patient. The HCP will be informed to screen all homeless patients for diabetes, substance abuse,
mental illness, and assess for evidence of sexual assault. Patients who are homeless will receive a
physical assessment as well as an assessment of availability of food, clothing, and shelters (Hauff
& Turner, 2014). The sixth and final topic will discuss care of the homeless person in the ED
specifically. This is where the documentation process will be discussed in order to keep all
screening and documentation uniform throughout the ED. The ED staff will be told to allow an
ample amount of time to preform an assessment on the homeless patient. Ways to appropriately
screen and intervene with active psychosis, alcohol intoxication, and drug intoxication will be
discussed (Doran et al., 2013).
Once all of the staff trainings have been completed, a post test will be sent to all
participants. If one topic tests poorly, an email will be sent out with further education on that
topic. A date will then be set for the screening and documentation process to be added to the
electronic health records. Once completed, the recommendations will be implemented in the ED.
Evaluating the Outcomes
The outcome for the implementation of a best practice recommendations for homeless
health care is to improve care for homeless patients in the ED. During the process of evaluation,
it is imperative that the committee work with the hospitals quality improvement (QI) staff
(Dearholt & Dang, 2012). With assistance from the QI staff, metrics will be utilized to measure
the effectiveness of the recommendations. One way this will be measured is to identify those
who are homeless and seeking care in the ED and provide them with a satisfaction survey that is
administered by a committee member in the ED. The survey will apply a five-point Likert scale,
with one being dissatisfied and a five being very satisfied. The categories to be included will be:
satisfaction of the nursing staff, physicians, education, referrals, and overall satisfaction with the
care. This will then be compared to the baseline data collected prior to the implementation of the
recommendations. Assistance will be provided for those who require aid with the form. A $5.00
meal card will be given as compensation to those who participate in the survey. Secondly, chart
audits will be set in place for all HCP who have access to the electronic health records. This will
be completed by the committee. A standard form will be used to complete chart audits on a
random basis. The form will first assess if the homeless screening has been completed. If the
screening was positive, the form will continue to assess if appropriate interventions were
completed and documented. The form will be a simple yes or no checklist; if the appropriate
intervention was completed, a yes will be checked and if not, a no will be checked. A warning
will be issued for a first strike of non-compliance. A second strike will warrant correctional
measures. Once all data has been collected, the information will be generated into a bar graph
and further evaluated.
Reporting Outcomes to Stakeholders
The final step in the John Hopkins Nursing Evidence-Based Practice Model is to
effectively report the findings to the organizations stakeholders (Dearholt & Dang, 2012). For
these recommendations, the results from the patient survey and from the chart audits will be
presented to ED leaders. This includes the department head and nurse manager for the ED.
According to Dearholt and Dang (2012), the information should be communicated appropriately
and in an executive format which follows organizational templates. One model that is suggested
is the PET model (Practice question, Evidence, and Translation) (Dearholt & Dang, 2012). Table
4 provides an example of a PET template for the implementation of a best practice
recommendations for HCP caring for homeless patients in the ED.

Table 4.
Template for Executive Summary Using PET
Problem
Homeless patients commonly use the ED as their primary means of health care. Many HCP in
the ED do not know the best ways to treat this vulnerable population, so optimal care is not
provided. Suboptimal care leads to unnecessary acute care hospitalization/rehospitalization of
the homeless patient and an inadequate use of available resources.
Practice Question
What are the most effective recommendations and interventions to provide optimal care to the
homeless patient in the ED?
Evidence
The search engines that were utilized were EBSCO and PubMed. Keywords to locate
information included homeless with subheadings of health care and access to; 15
articles were reviewed.
Translation and Recommendations

1. Form a committee to take leadership in implementing the recommendations.
2. The committee will evaluate the current status of homeless health care in the ED by
utilizing a survey.
3. A committee member will educate ED HCP on the best practice recommendations for ED
care of the homeless patient.
4. A charting system to screen for homelessness and to document interventions will be
implemented.
5. The recommendations will be initiated into the ED protocol, which will be developed by
the committee.
6. Ongoing evaluation will be conduced a 6 months, 1 year, and 2 years.
Adapted from Dearholt, S. L., & Dang, D. (2012). John Hopkins nursing evidence-based
practice: Model and guidelines. (pp. 155-156). Indianapolis, IN: Sigma Theta Tau International.
Summary
The purpose of this intervention is to assist HCP who work in the ED to provide optimal
care to homeless patients through implementation of best practice recommendations. As many
homeless people wait until an emergency situation to seek medical attention, the ED becomes the
primary site of care for many of these patients. Through excellent patient care and appropriate
referrals, optimal care can be provided to homeless patients in the ED. In addition to a decrease
in ED use, this thesis aims to prevent unnecessary hospitalizations by proving adequate ED
instructions and referrals. Implementation of the recommendations will include a survey to gain
baseline data. Then, a training on homeless health care will be required of all staff members.
Education will focus on screening for homelessness, intervening appropriately, and providing
proper referrals. A section in the electronic charting system will be employed to confirm that all
documentation is uniform throughout the ED. A post survey will then be initiated to determine
the effectiveness of the intervention. Finally, chart audits will be utilized to insure compliance.
With implementation of the above recommendations, homeless patients will receive high quality
care in the ED.

References
Bharel M, Creaven B, Morris G, Robertshaw D, Uduhiri K, Valvassori P, Wismer B, Meinbresse
M, Sergeant P. (2011). Health care delivery strategies addressing key preventive health
measures in homeless health care settings. Health Care for the Homeless Clinicians'
Network, , 29.
Burda, C., Haack, M., Duarte, A., & & Alemi, F. (2012). Medication adherence among homeless
patients: A pilot study of cell phone effectiveness. Journal of the American Academy of
Nurse Practitioners, 24(11), 675-681. doi:10.1111/j.1745-7599.2012.00756.x
Chrystal, J., Glover, D., Young, A., Whelan, F., Austin, E., Johnson, N., Pollio, D., Holt, C.,
Stringfellow, E., Gordon, A., Kim, T., Daigle, S., Steward, L., & Kertesz, S. (2015).
Experience of primary care among homeless individuals with mental health conditions. PloS
One, 2(10) doi:10.1371/journal.pone.0117395
Currie, L., Patterson, M., Moniruzzaman, A., McCandles, L., & Somers, J. (2014). Examining
the relationship between health-related need and the receipt of care by participants
experiencing homelessness and mental illness. BMC Health Services Research, 14(1), 404.
doi:10.1186/1472-6963-14-404
DaRonco, D. (2014). Number of tucson homeless drops slightly. Retrieved from
http://tucson.com/news/local/number-of-tucson-homeless-drops-slightly/article_65ffa8e1-
4fc6-5ad9-9583-23aa2c5ad3d5.html
Dearholt, S.L., & Dang, D. (2012). In Fields B. (Ed.), John hopkins nursing evidence-based
practice: Model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.
DeGrace, T. (2011). The great depression facts, timeline, causes, pictures. Retrieved from
http://www.stockpickssystem.com/the-great-depression/
Doran, K., Vashi, A., Platis, S., Curry, L., Rowe, M., Gang, M., & Vaca, F.E. (2013). Navigating
the boundaries of emergency department care: Addressing the medical and social needs of
patients who are homeless. American Journal of Public Health, 103(2)
doi:10.2105/AJPH.2013.301540
Fischer, R. (2011). The history of homelessness in america 1640s to present. Retrieved from
http://www.dceh.org/the-history-of-homelessness-in-america-1640s-to-present/
Frontline. (2005). Deinstitutionalism: A psychiatric "titanic". Retrieved from
http://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html
Hauff, A., & & Turner, M. (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
Hunter, C. E., Palepu, A., Farrell, S., Gooses, E., OBrien, K., & Hwang, S. W. (2015). Barriers
to prescription medication adherence among homeless and vulnerably housed adults in three
canadian cities. Journal of Primary Care & Community Health, 6(3)
doi:10.1177/2150131914560610
Kertesz, S. G., McNeil, W., Cash, J. J. Desmond, R., McGwin, G., Kelly, J., Bagget, T. P.
(2014). Unmet need for medical care and safety net accessibility among birmingham's
homeless. Journal of Urban Health, 91(1), 33-45. doi:10.1007/s11524-013-9801-3
Levin, J. B., Seifi, N., Cassidy, K. A., Tatsuoka, C., Sams, J.,Akagi, K. K., & Sajatovic, S.
(2014). Comparing medication attitudes and reasons for medication nonadherence among
three disparate groups of individuals with serious mental illness. The Journal of Nervous
and Mental Disease, 202(11) doi:10.1097/NMD.0000000000000201

National Coalition for the Homeless. (2016). Homelessness in america. Retrieved from
http://nationalhomeless.org/about-homelessness/
National Health Care for the Homeless Council. (2017). What is the official definition of
homelessness? Retrieved from https://www.nhchc.org/faq/official-definition-homelessness/
OBrien, K. K., Schuttkeb, A., Alhakeemc, A., Donnelly-Swifta, E., Keogha, C., OCarrolld, A.,
OSullivan, K., Galvina, R., Fahey, T. (2015). Health, perceived quality of life and health
services use among homeless illicit drug users. Drug and Alcohol Dependence, 154, 139-
145. doi:http://dx.doi.org/10.1016/j.drugalcdep.2015.06.033
OToole, T. P., Johnson, E. E., Borgia, M. L., & Rose, J. (2015). Tailoring outreach efforts to
increase primary care use among homeless veterans: Results of a randomized controlled
trial. Journal of General Internal Medicine, 30(7) doi:10.1007/s11606-015-3193-x
Savage, C. L., Lindsell, C. J., Gillespie, G. L., Lee, R. J., & Corbi. A. (2008). Improving health
status of homeless patients at a nurse-managed clinic in the midwest USA. Health & Social
Care in the Community, 16(5), 469-475. doi:10.1111/j.1365-2524.2007.00758.x
The U.S. Department of Housing and Urban Development. (2016). The 2016 annual homeless
assessment report (AHAR) to congress. Retrieved from
https://www.hudexchange.info/resources/documents/2016-AHAR-Part-1.pdf
Tomita, A., & Herman, D. B. (2015). The role of a critical time intervention on the experience of
continuity of care among persons with severe mental illness after hospital discharge. The
Journal of Nervous and Mental Disease, 203(1) doi:10.1097/NMD.0000000000000224
Townsend, M. C. (2014). In Clay J. (Ed.), Essentials of psychiatric mental health nursing (6th
ed.). Philadelphia, PA: F. A. Davis.

Weber, M., Thompson, L., Schmiege, S., Peifer, K., & & Farrell, E. (2013). Perception of access
to health care by homeless individuals seeking services at a day shelter. Archives of
Psychiatric Nursing, 27(4), 179-184. doi:10.1016/j.apnu.2013.05.001
White, B. M., & Newman, S. D. (2014). Access to primary care services among the homeless A
synthesis of the literature using the equity of access to medical care framework. Journal of
Primary Care & Community Health, 6(2) doi:0.1177/2150131914556122
Wise, C., & Phillips, K. (2013). Hearing the silent voices: Narratives of health care and
homelessness. Issues in Mental Health Nursing, 34(5), 359-367.
doi:10.3109/01612840.2012.757402

Thesis PDF

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Thesis PDF

Încărcat de

Drepturi de autor:

Formate disponibile

Running head: BEST PRACTICES FOR HOMELESS HEALH CARE 1

EVIDENCED-BASED RECOMMENDATIONS FOR HEALTH CARE

PROFESSIONALS IN THE EMERGENCY DEPARTEMENT WORKING WITH THE

HAILEY NICOLE PETTIS

A Thesis Submitted to The Honors College

In Partial Fulfillment of the Bachelors degree

THE UNIVERSITY OF ARIZONA

Patty Goldsmith, MS, RN, APHN-BC

transportation, cost, insurance, paperwork, knowledge about resources, communication issues,

implemented into an ED in Tucson, Arizona through staff training and evaluation.

Background and History of the Homeless Population

fathers before being welcomed into the community (Fischer, 2011).

hobo," tramp," and bum (Fischer, 2011).

deinstitutionalization. Beginning in 1955, Thorazine became available in mass quantities and

streets and in prisons (Frontline, 2005).

Significance of the Problem

accommodations, and an individual who is a resident in transitional housing (National Health

2,110 people experiencing homelessness in Tucson (DaRonco, 2014). Although homelessness is

becoming homeless than the general U.S. population.

48,000 homeless veterans, males represent 92% of the population.

Important Terms Defined

A person who had been homeless for an

Homeless individuals that enter the shelter

Those who transition in and out of

quality health care along with appropriate referrals to needed care.

utilized to create best practice recommendations.

Mental Health and Substance Abuse

Burda et al. (2012) conducted a quasi-experimental, prospective pilot study to evaluate

the possibility of monitoring medication adherence of homeless people with a psychiatric

and the results were congruent with similar research.

selected from a nurse-managed clinic and interviewed. A nursing intervention of an assessment,

due to the nature of the studys design.

OBrien et al. (2015) conducted a cross-sectional study in order to examine the

lead to bias. A strength of the study was an adequate sample size.

Levin et al. (2014) designed a cross-sectional analysis to compare attitudes towards

antipsychotics, and the third group consisted of 30 participants with schizophrenia or a

modules: psychoeducation, medication routines, communication with providers, and substance

Barriers for Homeless People Seeking Care

the other articles in this review of literature.

Weber, et al. (2013) conducted a collaborative, community based research project to

Hauff and Turner (2014) designed a mixed-methods study to understand barriers to

to connect homeless patients with services aimed to assist in recovery, medication

theme of same/different described an us/them mentality in which homeless people reported

homeless population within the health care system.

Kertesz et al. (2014) created a cross-sectional, community-based survey to assess the

random sample, which increased the validity of the article.

Participants were interviewed at baseline, a 4 week follow up interview, and a 6-month

White and Newman (2015) conducted a quasi-systematic review of twelve articles to

Homelessness and Emergency Department Use

semi-structured interviews with ED physicians between two hospital residency programs.

the homeless in the ED to increase their overall quality of life.

Best Practice Recommendations

approach to health care. Interventions addressed include screenings, consultation, advocacy,

discharge and respite programs.

Best Practice Recommendations for Providing Optimal Care to the Homeless

Education sessions should be implemented to provide information on homeless people and to

homeless patients in the ED.

Best Practice Recommendations Components

In-Text Citation Level of

- Consult case management

- Do not profile patient based on

- Maintain a updated list of

Level of Evidence Description