Running head: EDUCATION ABOUT HEALTHCARE AMONG HOMELESS 1

POPULATION

Evidence Informed Strategies to Enhance the Use and Experience of Healthcare by Homeless

Individuals

Jessica Oh

University of Arizona

College of Nursing
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 2

TABLE OF CONTENTS

I. Chapter 1 – Introduction

A. Statement of Purpose

B. Historical Background of Healthcare Use by the Homeless

C. Significance of Problem

D. Summary

II. Chapter 2 – Literature Reviews

A. Introduction

B. Prospective Validation of a Predictive Model that Identifies Homeless People at

Risk of Re-Presentation to the Emergency Department

C. The Revolving Hospital Door: Hospital Readmissions Among Patients Who Are

Homeless

D. Predictors of Emergency Department Visits and Inpatient Admissions Among

Homeless and Unstably Housed Adolescents and Young Adults

E. Increasing Access – A Qualitative Study of Homelessness and Palliative Care in a

Major Urban Center

F. Homeless Health Needs: Shelter and Health Service Provider Perspective

G. The Perceptions of Homeless People Regarding Their Healthcare Needs and

Experiences of Receiving Health Care

H. Summary

III. Chapter 3 – Best Practice Protocol: Education for the Healthcare Staffs

A. Practice Protocol

B. The Need for Education

EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 3

C. The Limited Access for Transportation

D. Summary

IV. Chapter 4 – Implementation and Evaluation

A. Implementation

a. Training Guides and Testimonies

b. Implement the Practice Change

c. Summary

B. Evaluation

a. Evaluation of the Impact of the Practice Change

b. Activities to Sustain Change

C. Potential Barriers and Future Recommendations

D. Summary
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 4

Chapter 1

Introduction

Statement of Purpose

The purpose of this thesis is to develop best practice recommendations to improve the

healthcare for people experiencing homelessness. An important aspect of this is to foster the

relationship between the healthcare team and homeless individuals. The thesis contains evidence-

based research articles that inform care for homeless individuals. The articles address the

perspectives of both the healthcare team and those in the homeless. To improve nursing care, the

knowledge of the homeless will be discussed in further detail.

Historical Background of the Homeless Population

The first documented presence homeless individuals were back in 1640; homelessness

has been increasing in the United States since then. About 2.5 to 3 million people experience

homelessness each year (“Homelessness in America: Overview of Data and Causes”, 2015).

About 85% of the homeless persons are individuals, and 15% are families (National Coalition of

the Homeless, 2014). According to National Health Care for the Homeless Council (2017), there

are different types of homelessness. There are individuals who face short-term, long-term, and/or

chronic lengths of time. There is no single cause for homelessness; however, people who live in

poverty are at the highest risk. There are about 48.2 million people in poverty (“The State of

Homelessness in America 2016”, 2016). Because health problems among individuals who are

experiencing homelessness may have great levels of severity, this may lead to higher rate of

mortality (Fleish & Nash, 2017). Homeless individuals are more likely to require emergency

department services because of the high risk for injuries and assaults. Health concerns that the
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 5

homeless population face include mental illness, substance abuse, bronchitis, pneumonia, skin

infections, and sexual abuse (“Homeless Health Concerns”, 2016).

There are five states with the highest rate of homelessness: California, New York,

Florida, Texas, and Massachusetts (National Coalition of the Homeless, 2014). Even though

these states have high ranked hospitals and clinics, the resources for the homeless are limited. In

addition, the homeless community is filled with different types of homelessness: short-term,

long-term, or chronic (National Health Care for the Homeless Council, 2017). Short-term

homelessness is a group of individuals who have recently become homeless (<6 months). Long-

term homelessness is a group of individuals who have been homeless for over 6 months. Chronic

homelessness is a group individuals who have comorbidities and have been living in poverty for

more than 6 months.

Significance of Problem

Homeless individuals lack access to healthcare, hospitals, and/or clinics as compared to

people who can afford housing. Lack of health insurance, money to pay for insurance, and lack

of a job or low wages are the main limitations of owning a home. Homeless people face barriers

to the access of care. They face great adversities that discourage their use of healthcare. For

example, the lack of insurance impacts access to healthcare for the poor and people experiencing

homelessness. The lack of insurance decreases the knowledge of health issues (National Health

Care for the Homeless Council, 2017). Because those who cannot afford insurance do not have

the resources to access care for health problems, they are at risk for higher rates of mortality.

Many homeless individuals believe that their social backgrounds and economic status is a major

disincentive to the eyes of the health teams. Homeless individuals experienced that health care
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 6

professionals do not treat them equally compared to those who are able to afford care (Rae &

Rees, 2015).

Summary

The purpose of this thesis is to develop best practice recommendations to enhance

healthcare of people experiencing homelessness, including improving relationships between

healthcare providers and people experiencing homelessness. Over decades, the rate of poverty

had been increasing. Health care for individuals is limited due to the lack of money, insurance,

and lack of employment (National Coalition of the Homeless, 2014). Homeless people have been

affected more by sickness than those who live with adequate finances (National Coalition of the

Homeless, 2014). To educate the healthcare team, an in-class training that teaches providers

about the healthcare needs of people experiencing homelessness, and enhances cultural

sensitivity to improve access to care, and the provision of care to people experiencing

homelessness.

Chapter 2

Introduction

The following literature describes research studies that address experiences that doctors,

nurses, and homeless individuals had when interacting with one another. Databases used to find

these articles included CINHAL, and Pubmed. Main search terms that were used were,

“homelessness” and “health care” to find how these two words correlated with each other. Also,

a subheading such as, “relationships” narrowed down the need for critical information. The

articles were published between 2012-2017. The studies analyzed below are organized in groups

of similarities: 1) use of emergency rooms and/or re-admission to the hospital, 2) access to health

care, 3) healthcare needs, and 4) the perspectives on healthcare.

EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 7

The Use and Experience of Healthcare by the Homeless Population

As of January 2015, there were 560,000 people who were homeless (“Homelessness in America:

Overview of Data and Causes”, 2015). The homeless population accounts for people who are

living in shelters, in public places, or in the streets. One common aspect of the homeless

population includes individuals with no permanent housing (“What is the official definition of

homelessness?”, 2016). The root cause of homelessness is complex and innumerable; there is

more than one factor that leads to homelessness. Some aspects that lead to homelessness are

mental disorders, substance abuse, poverty, and the disapproval of homosexuality in the homes

(Fazel, Geddes, & Kushel, 2015). Because poor health may lead to homelessness, homeless

persons need healthcare assistance. Homeless individuals have high rates of physical and health

distress due to competing demands of food, shelter, and health care needs (Lin, Bharel, Zhang,

O’Connell, & Clark, 2015).

Prospective validation of a predictive model that identifies homeless people at risk of re-

presentation to the emergency department

This research study was designed to predict the risks of homeless people who are likely

to revisit the emergency hospital after discharge (Moore et al., 2011). A screening tool,

Behavioral Model of Vulnerable Populations (BMVP), was used to identify people at risk for

readmission to hospitals. The researchers incorporated previous data from 2003-2004 and 2009

to add more information to the findings, and to use past findings to make a prediction about

hospital’s re-admission (Moore et al., 2011). The research used a prospective cohort design that

measured the total numbers of visits to the emergency department within a month after

discharge. The recruitment of participants used a broad technique; the researchers labelled any

patient that came to the hospital who were confirmed to being homeless, which came to a total of
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 8

211 patients out of 2,888 total patients. The patients were then screened as they revisited the

same emergency department which took place at an adult, tertiary care hospital in an Australian

city (Moore et al., 2011). Of the 211 homeless patients, 90 of them came back for further

assistance. Even though the homeless population was smaller than the non-homeless population,

the readmission rates were 43% in the emergency room. When the BMVP was used, the findings

revealed that the likelihood of homeless people being re-admitted to the hospitals after discharge

would increase to 68% if no further action was taken (Moore et al., 2011). The screening tool

identified that age, gender, and diseases were risks for re-admission for hospitalization. (Moore,

et al., 2011).

The revolving hospital door: Hospital readmissions among patients who are homeless

Doran et al.’s (2013) study used a retrospective chart review of homeless individuals who

had access to the urban teaching hospital where the study took place. Through this study, the

researchers aimed to reveal the reason for readmission, and the readmission rates of homeless

patients. The researchers requested that the providers screen patients for homelessness by using

an electronic medical record flag and a manual chart review (Doran et al., 2013). The use of two

charts were to minimize the miscalculations of homeless patients. During the study, the total

homeless population that visited this hospital were 113 people. The data and findings were

extracted from the patients’ medical records from discharge to readmission; two authors of this

study analyzed the data to ensure accuracy (Doran et al., 2013). One hundred thirteen homeless

patients were readmitted to the hospital 266 times; 50.8% concluded to be the readmission rate

(Doran et al., 2013). The researchers also revealed that the admitting diagnosis were primarily

related to drug and alcohol use, abdominal pain, nausea and vomiting. (Doran et al., 2013).

When compared to other findings of non-homeless patients, the readmission rates of homeless
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 9

patients were exceptionally higher. These findings supported the objective of identifying the

reason and rates for readmission.

Through the screening process, the researchers identified reasons for readmission which

correlated to the readmission rates. However, the results of this study were limited to one

hospital.

Accuracy of self-reported health care use in a population-based sample of homeless adults

Hwang, Chambers, & Katic (2016) stratified their sample to get a ratio of 2:1:1, single

adult men, single adult women, and family adults respectively to conduct a self-reported survey

study. To obtain this sample ratio, 1,163 homeless adults were recruited. These participants were

identified as persons who were living in any shelters, public places, vehicles, abandoned

buildings, and someone’s home (Hwang, Chambers, & Katic, 2016). The purpose of this study

was to determine the accuracy of self-reported visits to any hospital system by the homeless

adults (Hwang, Chambers, & Katic, 2016). When the data was analyzed, the researchers

discovered that the reason for hospital visits were either under-reported or over-reported. The

under-reported conditions involved alcohol abuse whereas the over-reported conditions involved

in physical and sexual abuse (Hwang, Chambers, & Katic, 2016). The different categories of

participants, single men, single women, and family adults, did influence the results of the health

reports. Even though some data were skewed by the due to the response variations, the overall

findings were reported according to the participants’ responses (Hwang, Chambers, & Katic,

2016).

Predictors of emergency department visits and inpatient admissions among homeless and

unstably housed adolescents and young adults

EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 10

The study by Mackelprang, Qiu, & Rivara (2015) used a retrospective cohort study that

included mixed population of adolescents and young adults (N=402). Within this study, the

researchers had 4 main purposes: 1) to report prevalence and admissions of the homeless

adolescents and young adults to the emergency department, 2) to identify the statistics of the use

of healthcare by the homeless youth and teens, 3) to recognize the variables that lead to hospital

admissions, and 4) to predict the demographics for readmission to the healthcare (Mackelprang,

Qiu, & Rivara, 2015). The researchers focused on the group of people who was identified as

homeless or had no address except to homeless shelters. The study used a descriptive statistic to

characterize the patients and their uses of hospitals. A total of 1151 emergency department visits

by the homeless participants were documented. Exactly half of the participants (n=201) had

revisited the emergency department. Most of the women who sought treatment received medical

assistance for assault-related injuries; most male participants were treated for alcohol disorders

(Mackelprang, Qiu, & Rivara, 2015). The variables that lead to the initial hospitalization

hospitalization were injury, illness, and comorbidity (Mackelprang, Qiu, & Rivara, 2015). The

admission cause consisted of many chronic conditions such as alcohol abuse, pregnancy-related

injuries, psychiatric disorders. (Mackelprang, Qiu, & Rivara, 2015). Readmission rates depended

on the severity of the injury and the living situation (Mackelprang, Qiu, & Rivara, 2015).

This study took place at a large, urban teaching hospital which limited the findings to

only a specific setting. However, the researchers identified the main reasons for hospital

admission and readmission among this sample.

Increasing access – A qualitative study of homelessness and palliative care in a major

urban center

Krakowsky, Goffine, Brown, Danziger, & Knowles (2012) conducted a qualitative study
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 11

using semi-structured interview to determine how to promote access to palliative care for

homeless people who are seeking care. Seven providers were selected from St. Michael’s

Hospital to be interviewed. The providers cared for dying people either as nurses or outreach

workers (Krakowsky et al., 2012). The participants were interviewed with a semi-structured

interview that discussed the topic of the use of palliative care for terminally homeless

individuals. According to participants, homeless individuals were hesitant to access care due to

previous experiences with the providers or health services. In addition, the participants provided

information to increase access to healthcare which were categorized into four themes identified

by thematic analysis: 1) increasing positive interaction between the health care system and the

homeless, 2) training staff to deal with the unique issues confronting the homeless, 3) providing

patient-centered care, and 4) diversifying the methods of delivery (Krakowsky et al., 2012).

These themes revealed the barriers to palliative care and advanced the knowledge for better care

for the homeless population (Krakowsky et al., 2012).

The themes presented the perspectives of only the homeless care providers which limits

the findings to a small population. Hence, the results did not address the experiences of the

homeless persons, themselves. Future studies could recruit a mixture of the healthcare providers

and the homeless individuals.

Homeless Health Needs: Shelter and Health Service Provider Perspective

The main goal for this study was to identify healthcare needs and barriers to care

experienced by homeless people (Hauff & Secor-Turner, 2014). Hauff & Secor-Turner (2014)

recruited a mixture of homeless shelter staff (n=10) and health service staff (n=14) through

convenience sampling. This study used a mixed method design to collect data that consisted of

semi-structured interviews. The interview questions identified four themes that were analyzed by
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 12

a descriptive content analysis method: 1) health needs, 2) barriers to care, 3) respite care needs,

and 4) support service needs (Hauff & Secor-Turner, 2014). According to Hauff & Secor-Turner

(2014), the outcome was consistent with previous research. Other research studies have found

that barriers to healthcare among the homeless involved limited transportation, shortage of

money, psychological problems, and low trust in healthcare professionals (Nickasch &

Marnocha, 2009). When the participants were interviewed by Hauff & Secor-Turner (2014), the

participants stated that healthcare is not a priority to the homeless individuals. In addition, this

population feels judged, offended, and disappointed towards the healthcare providers (Hauff &

Secor-Turner, 2014). The hospital staffs are limited to the scope of care if the patient no longer

needs medical attention, because of these situations, the homeless individuals feel abandoned and

no longer seek help. Due to such barriers to hospitalization, the participants recommended

medical respite that will be cost effective and beneficial to the homeless persons. However,

during the interview, the participants realized more education was needed regarding

homelessness for all healthcare providers.

This study identified the issues from the eyes of the healthcare staffs. Similar to the study

by Krakowsky et al. (2012), the results were restricted only to the staff’s perspective. Study of

both the staff and homeless patients would expand the perspective regarding healthcare needs.

The perceptions of homeless people regarding their healthcare needs and experiences of

receiving health care

Rae & Rees (2015) conducted a phenomenological study to explore homeless persons’

experiences of healthcare and how experiences with care impact their attitudes toward receiving

care. The sample was recruited through convenience sampling. This study involved fourteen

single homeless adults (two women and twelve men) from a hostel where the study took place.
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 13

(Rae & Rees, 2015). There was bias in finding the participants due to the limitation of

availability and willingness to participate (Rae & Rees, 2015). The sample size only included

participants who were defined as living on the streets, living in temporary shelters or homes, who

were willing to carry out the whole interview process, and who were 18 years and older. The

study was conducted for 9 months between September 2012 to May 2013, and the participants

were interviewed for multiple times for a 3-week period between the 9 months. (Rae & Rees,

2015). The researchers discovered three themes: 1) expressed health needs, 2) healthcare

experiences, and 3) attitudes towards the healthcare (Rae & Rees, 2015). To express the need for

help, the participants were only willing to seek hospitalization if they were extremely sick or

hurt. Others stated that they would rather spend the money on alcohol than to seek hospital care

(Rae & Rees, 2015). The participants had both positive and negative experiences in a healthcare

setting: some participants felt that the doctors assisted them in their needs, but the other

participants expressed that the health providers did not care about the homeless (Rae & Rees,

2015). Their attitudes toward the healthcare system were mostly negative. They felt very

uncomfortable, and were skeptical about the providers. These findings suggest that homeless

individual have priorities regarding their experiences of healthcare; and previous encounters with

healthcare providers did affect their future health seeking behaviors (Rae & Rees, 2015).

Summary

Reviewed studies provided information about people experiencing homelessness view

their experiences with the healthcare system, and how these perceptions impact their subsequent

use of healthcare services. The findings indicate that homeless people often require care due to

conditions associated with their living environment. Homeless individuals seek care for health

reasons that are often associated with being homeless, such as infections, lungs issues, and flu-
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 14

like symptoms. Because the rate of homelessness is increasing in the United States, the

admission rates increase, as evidenced by Doran et al’s study. These individuals are more likely

to use the emergency room for their health issues because they do not have access to primary

care. Due to the lack of care, the re-admission rates are increased. Additionally, homeless people

face barriers, such as transportation, financial constraints, lack of health insurance, and negative

past experiences with healthcare. Even though there are multiple studies regarding homeless

individuals’ access to healthcare, the solutions for the homeless individuals to be medically

treated are lacking. In addition, the impact of positive interactions between the healthcare

providers and the homeless population is an area for further research.

Chapter 3

Best Practice Protocol: Education for the Healthcare Staffs

The purpose of this thesis was to create evidence-based recommendations for education

about the healthcare needs people experiencing homelessness through an in-class

education/training for the healthcare providers. This education/training will guide providers to

effectively provide care to those experiencing homeless through cultural sensitivity, therapeutic

communication, and referrals to community resources. The training will provide information on

how to develop a trusting relationship between healthcare providers and the individual

experiencing homelessness. Additionally, the training will provide recommendations on how to

care for people experiencing homelessness by recognizing medical issues. This chapter will

present evidence-based recommendations on ways to enhance access and improve healthcare for

people experiencing homelessness.

There is a documented lack of communication between healthcare providers and the

homeless individuals. Some individuals feel that they are being judged by healthcare providers,
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 15

and they do not wish to return because of the negative experience (Rae & Rees, 2015). As the

individuals prolong hospitalization, their conditions become worse and detrimental. Because it is

impossible to treat every homeless individual, educating the staffs will be the best benefit for

both parties. Knowledge about the needs of homeless individuals is limited, and healthcare

professionals lack skills and knowledge to provide effective care. The healthcare providers’ lack

of knowledge about homelessness and lack of communication results in a negative impact on the

homeless individuals.

The Need for Education

To improve healthcare for people experiencing homelessness, health care provider

education should include the main types of comorbidities that homeless individuals face, the

hardships they face, and how to provide comfort of care for a regular inpatient individual. The

homeless individuals who are treated negatively in a healthcare setting perceive that seeking

treatment is an obstacle (Rae & Rees, 2015). Homeless individuals feel that they are insignificant

when their needs are inadequately addressed, which leads them to stray away from healthcare.

However, those who experienced positive encounters with healthcare providers made efforts to

receive treatment. Treating the homeless individuals with respect is critical for them to seek and

engage in treatment.

The Limited Access for Transportation

According to Bonin et at., (2010), the homeless people is at risks for communicable

diseases, abuse, behavioral problem, and co-morbid diseases. Additionally, these patients lack

transportation and social support, limiting their access to care. Providing information to the

healthcare staffs regarding the use of resources, such as social workers, could increase the access
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 16

to healthcare. Teaching the staffs about outreach sites, such as the streets, soup kitchens, and

shelters can promote health for these individuals.

Summary

The initial meeting between the healthcare professionals and patients is critical for

building rapport, and effective healthcare. Lack of effective communication between homeless

individuals and healthcare providers has been identified by people experiencing homelessness as

a barrier to seeking and receiving healthcare. Education about how to effectively communicate

with, and address the needs of patients who experience homelessness, will likely result in

improved care for these vulnerable patients.

Chapter 4

Implementation and Evaluation

This chapter introduces the implementation of five in-class trainings for healthcare

professionals about health concerns in homeless population. The in-class training will provide

education from health concerns that the individuals living in poverty or homelessness face to

outreach and/or resources that the healthcare providers can utilize. Because there is a need of

improving healthcare among homeless population, educating the healthcare staffs about the

holistic care and the priorities of concern for individuals facing homelessness could potentially

decrease health issues in homeless populations.

Before the training begins, all the staffs will take a pre-test to set their baseline

knowledge about the issues in homelessness. In-class trainings will incorporate different topics

for each week, for 8-weeks. The training will consist of: Background of Homelessness and

Significance of the Problem, High Priorities Medical Issues, Therapeutic Communications,

Working with Nurse Case Managers, and Treatment Plans and Resources. These in-class
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 17

trainings will be mandatory for all healthcare staffs; each topic will be covered once a week. It is

necessary to have a face-to-face meeting because the meetings will feature testimonies by

individuals who have or are facing homelessness.

Lastly, evaluating the effectiveness of the trainings will be addressed. The evaluation will

consist of a post-test to identify the increase in knowledge. This will evaluate how the training

impacted the change on structure, process, and outcome measures. Additionally, this chapter will

provide the strengths and limitations that this implementation face.

Implementation

Training Guides and Testimonies

The training will address the challenges of delivering healthcare to individuals facing

poverty. It will consist of five topics: Background of Homelessness and Significance of the

Problem, High Priorities Medical Issues, Therapeutic Communications, Working with Nurse

Case Managers, and Treatment Plans and Resources. Because some topics might take couple of

hours, the training will be implemented once a week. Additionally, there is extra pay provided

for participating in the trainings for it is mandatory. The course starts with the fundamental

knowledge regarding the history of homelessness. After each course, the staffs are introduced to

ways to implement holistic care. Starting from the most simplistic views to expanding ways to

apply critical thinking to individuals experiencing homelessness builds stronger foundations and

improves learning (Dunlosky, Rawson, Marsh, Nathan, & Wilingham, 2013). Incorporating

testimonies and/or personal stories is a strategy to improve the learning process (Slesiter, 2014).

For the speaker to relay the important message, s/he should describe the main ideas and

frequently answer questions (Slesiter, 2014). Because hours of training and new information can
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 18

be tiring and exhausting, including personal stories from a person who faced or is still facing

homelessness leaves a powerful message behind.

Implement the Practice Change

During the implementation stage, there will be multiple days of the week when staff

members will come together according to their schedules. On the first day of training, the staffs

will be given pre-tests to measure their baseline knowledge. The training will start from the

morning and will end according to the topic. The staff members will receive extra pay for

attending the training. Additionally, there will be testimonies for every five sessions to increase

the learning process. The staff members are highly encouraged to take notes and ask questions

during the training and presentations to enhance their time and knowledge. At the final session,

the staff members will be give post-tests to measure the effectiveness of the implementation.

Summary

The implementation stage provides a face to face evidence informed strategy to enhance

the experience of healthcare among homeless individuals. This in-class training ensures that all

staff members are being educated about the issues concerning the homeless population and ways

to provide holistic care. The training program brings personal stories into the education process.

Lastly, the next section presents the evaluation of implementing in-class training.

Evaluation

The evaluation stage is the last step to apply evidence informed strategies to enhance

education. Graham, Tetroe, & the KT Theories Research Group (2007), mentions that this stage

will determine the effectiveness of the impact of the practice change (as cited in Melnyk &

Fineout-Overholt, 2011).

Evaluation of the Impact of the Practice Change

EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 19

During the evaluation of the practice change, the educators will evaluate the change on

structure, process, and outcome measures (as cited in Melnyk & Fineout-Overholt, 2011). Like

mentioned above, the staffs will be given pre/post-tests to measure their baselines and their

knowledge development. The post-test can be evaluated by determining whether the education

and training was effective for the staffs.

Activities to Sustain Change

An additional way to sustain the changes is to track the personal health information of

homeless individuals that are utilizing the emergency department in the hospital. This evaluation

can be implemented by the help of nurse case managers. Nurse case managers are resources for

those who need help with difficult situations and find other resources that are beneficial. The

case managers can determine what the healthcare providers are doing to increase the homeless

individual’s experience in the hospital setting. For example, the case managers can identify what

the healthcare staff recommended and what further treatment plan is needed.

Potential Barriers and Future Recommendations

The major barrier that this project faces is the lack of follow-up with homeless

individuals. There is not a certainty that the homeless individual will consistently use the same

hospital, meaning that there is no indicator of whether the implementation was beneficial for

those vulnerable patients. Additionally, this project focuses mainly on educating the healthcare

staffs, which might include bias. Lastly, this project included mostly Level V and Level VI

evidence-based article, which could potentially increase the likelihood of bias.

Recommendations for future research includes ways to educate the homeless population.

Using outreach programs to educate the people living on the streets could benefit further research

and priorities of care. Additionally, a research can be conducted to implement transportation for
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 20

individuals to local clinics that specializes in the homeless populations’ needs rather than using

emergency departments that could turn the patients away.

Summary

The purpose of this thesis was to develop evidence informed strategies to enhance the use

and experience of healthcare among homeless individuals. Homeless individuals were facing

barriers to seek healthcare, increasing the risk for comorbidities. The implementation provided

information about educating healthcare staffs to increase access care for individuals experiencing

homelessness. Additionally, this chapter introduced the evaluation process of the protocol that

uses pre/post-tests to find the baseline knowledge and the new information learned. It briefly

talks about the use of nurse case managers, for they know more referrals and advice for patients

who need additional resources.

EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 21

References

Bonin, E., Brehove, T., Carlson, C., Downing, M., Hoeft, J., Kalinowski, A., Solomon-Bame, J.,

& Post, P. (2010). Adapting your practice: General recommendations for the care of

homeless patients. National Health Care for the Homeless Council, 50.

Doran, M. K., Ragins, T. K., Iacomacci, L. A., Cunningham, A., Jubanyik, J. K., … Jeng, Y. G.

(2013). The revolving hospital door: Hospital readmissions among patients who are

homeless. Medical Care, 51, 767-773. doi: 0025-7079/13/5109-0767

Dunlosky, J., Rawson, A. K., Marsh, J. E., Nathan, J. M., & Willingham, D. T. (2013).

Improving students’ learning with effective learning techniques. SAGE Journal, 14, 4-58.

doi: 10.1177/1529100612453266

Fazel, S., Geddes, R. J., & Kushel, M. (2015). The health of homeless people in high-income

countries: descriptive epidemiology, health consequences, and clinical and policy

recommendations. The Lancet, 384, 1592-1540. doi: 10.1016/S0140-6736(14)61132-6.

Hauff, J. A. & Secor-Turner, M. (2014). Homeless health needs: Shelter and health provider

perspective. Journal of Community Health Nursing, 31, 103-117. doi:

10.1080/07370016.2014.901072.

Hwang, W. S., Chambers, C., & Katic, M. (2016). Accuracy of self-reported health care use in a

population-based sample of homeless adults. Health Services Research Journal, 51, 282-

301. doi: 10.1111/1475-6773.12329

Krakowsky, Y., Gofine, M., Brown, P., Danziger, J., & Knowles, H. (2012). Increasing access:

A qualitative study of homelessness and palliative care in a major urban center. American

Journal of Hospice and Palliative Medicine, 30, 268-270. doi:

10.1177/1049909112448925
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 22

Lin, C. W., Bharel, M., Zhang, J., O’Connell, E., & Clark, E. R. (2015). Frequent emergency

department visits and hospitalizations among homeless people with Medicaid:

Implications for Medicaid expanision. American Journal of Public Health, 105, 716-722.

doi: 10.2105/AJPH.2015.302693.

Mackelprang, L. J., Qiu, Q., & Rivara, P. F. (2015). Predictors of emergency department visits

and inpatient admissions among homeless and unstably house adolescents and young

adults. (2015). Medical Care, 53, 1010-1017. doi: 0025-7079/15/5312-1010

Melnyk, M. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare:

A guide to best practice. (2nd ed. p. 240). Philadelphia: Wolters Kluwer Health/Lippincott

Williams & Wilkins.

Moore, G., Hepworth, G., Weiland, T., Manias, E., Gerdtz, F. M., Kelaher M., … Dunt, D.

(2011). Prospective validation of a predictive model that identifies homeless people at

risk of re-presentation to the emergency department. Australasian Emergency Nursing

Journal, 15, 2-13. doi: 10.1016/j.aenj.2011.12.004

National Health Care for the Homeless Council. (2016). What is the official definition of

homelessness? Retrieved from https://www.nhchc.org/faq/official-definition-

homelessness.

National Law Center on Homelessness and Poverty. (2016, May 23). Homelessness in America.

Retrieved from https://www.nlchp.org/documents/Homeless_Stats_Fact_Sheet

Nickasch, B. & Marnocha, S. K. (2009). Healthcare experiences of the homeless. Journal

American Association of Nurse Practitioners, 1, 39-46. doi: 10.111/j.1745-7599

Rae, E. B. & Rees, S. (2015). The perceptions of homeless people regarding their healthcare

needs and experiences of receiving health care. Journal of Advanced Nursing, 71, 2096-
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 23

2107. doi: 10.1111/jan.1267

Sleister, H. M. (2014). Evidence-based strategies to improve memory and learning. Journal of

Microbiology and Biology Education. 15, 336-337. doi: 10.1128/jmbe.v15i2.790

Running head: EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 24

Appendix A

Table 1: Best Practice Protocol for Educating Healthcare Staffs on Communicating with the Homeless Population and Providing
Adequate Care

Content of Level of
Topics References
Education Evidence

Fazel, S., Geddes, R. J., & Kushel, M. (2015).

The health of homeless people in high-income
countries: descriptive epidemiology, health
consequences, and clinical and policy
 Poverty have positive correlation to recommendations. The Lancet, 384, 1592-
homelessness. When there is lack of 1540. doi: 10.1016/S0140-6736(14)61132-6.
Background and
housing, lack of adequate care, mental
Lifestyle of
illness, and substance use, there is a great Lin, C. W., Bharel, M., Zhang, J., O’Connell, Level VI
Homeless
chance of homelessness. E., & Clark, E. R. (2015). Frequent emergency
Individuals
 The homeless population is gradually department visits and hospitalizations among
increasing every year. homeless people with Medicaid: Implications
for Medicaid expanision. American Journal of
Public Health, 105, 716-722. doi:
10.2105/AJPH.2015.302693.

 Homeless population were more likely to Doran, M. K., Ragins, T. K., Iacomacci, L. A.,
readmit to hospitals than those who were not Cunningham, A., Jubanyik, J. K., … Jeng, Y. G Level VI
homeless. (2013). The revolving hospital door: Hospital
 Many readmitted mainly from substance use. readmissions among patients who are
Reasons for
 Clients were readmitted because they wanted homeless. Medical Care, 51, 767-773. doi:
Readmission
in-housing treatments. 0025-7079/13/5109-0767
 Some risk factors for readmission are age,
gender, and disease condition. Hwang, W. S., Chambers, C., & Katic, M.
(2016). Accuracy of self-reported health care
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 25

use in a population-based sample of homeless Level V

adults. Health Services Research Journal, 51,
282-301. doi: 10.1111/1475-6773.12329

Mackelprang, L. J., Qiu, Q., & Rivara, P. F.

(2015). Predictors of emergency department
visits and inpatient admissions among homeless
and unstably house adolescents and young Level VI
adults. (2015). Medical Care, 53, 1010-1017.
doi: 0025-7079/15/5312-1010

Moore, G., Hepworth, G., Weiland, T., Manias,

E., Gerdtz, F. M., Kelaher M., … Dunt, D.
(2011). Prospective validation of a predictive
model that identifies homeless people at risk of Level VI
re-presentation to the emergency department.
Australasian Emergency Nursing Journal, 15,
2-13. doi: 10.1016/j.aenj.2011.12.004

Krakowsky, Y., Gofine, M., Brown, P.,

Danziger, J., & Knowles, H. (2012). Increasing
access: A qualitative study of homelessness and
 Homeless individuals are hesitant to seek Level V
palliative care in a major urban center.
treatment from negative interactions with
American Journal of Hospice and Palliative
healthcare staffs.
Medicine, 30, 268-270. doi:
 The homeless population feels their medical
Healthcare Barriers 10.1177/1049909112448925
needs are rushed due to the inability to pay
hospital bills.
Hauff, J. A. & Secor-Turner, M. (2014).
 Individuals feel hurt, abandoned, and
Homeless health needs: Shelter and health
disappointed by the medical staffs. Level VII
provider perspective. Journal of Community
Health Nursing, 31, 103-117. doi:
10.1080/07370016.2014.901072.
EDUCATION ABOUT HEALTHCARE AMONG HOMELESS POPULATION 26

Krakowsky, Y., Gofine, M., Brown, P.,

Danziger, J., & Knowles, H. (2012). Increasing
access: A qualitative study of homelessness and
palliative care in a major urban center.
Level V
American Journal of Hospice and Palliative
Medicine, 30, 268-270. doi:
10.1177/1049909112448925
 The individuals feel that they are worthless
Hauff, J. A. & Secor-Turner, M. (2014).
Homeless in the eyes of hospital staffs.
Homeless health needs: Shelter and health
Individuals’  The homeless individuals had both positive
provider perspective. Journal of Community
Perspectives on and negative experiences, but they would Level VII
Health Nursing, 31, 103-117. doi:
Healthcare prefer not to visit the hospital due to stories
10.1080/07370016.2014.901072.
of hardships.

Rae, E. B. & Rees, S. (2015). The perceptions

of homeless people regarding their healthcare
Level VI
needs and experiences of receiving healthcare.
Journal of Advanced Nursing, 71, 2096-2107.
doi: 10.111/jan.12675.

 To improve communication, training staffs Krakowsky, Y., Gofine, M., Brown, P.,
to handle issues confronting homeless Danziger, J., & Knowles, H. (2012). Increasing
individuals. access: A qualitative study of homelessness and
Therapeutic
 Teach providers how to have positive palliative care in a major urban center. Level V
Communications
interactions with the homeless population by American Journal of Hospice and Palliative
using proper body language. Medicine, 30, 268-270. doi:
10.1177/1049909112448925