Transitional Care for Homeless Persons: An Opportunity for Nursing Leadership,Innovation,and Creativity

Homelessness in the United States

Homelessness is a national priority, receiving substantial attention and considerable public funding (Shumsky, 2012). Despite this, accurate data regarding homelessness and housing insecurity are difficult to capture for multiple reasons. People experiencing homelessness may not reveal their housing status because of fear of judgment or stigma (Greysen, Allen, Rosenthal, Lucas, & Wang, 2013). People “doubling up” by sleeping on couches or floors with friends and family may not be perceived as homeless. Many hospitals, clinics, and social service agencies do not routinely collect or track patient housing status (Greysen et al., 2013). The annual point-in-time count is currently the primary method of enumerating homeless individuals at the local, state, and national levels. The point-in-time count is a literal count of homeless persons in the United States conducted during a 24-hour period in the last week of January each year. The count is completed at the local or regional level; data are then combined to derive state and national homelessness totals. (More information on the point-in-time count can be found at https://www.hudexchange.info/hdx/guides/pit-hic/.)

Point-in-time count data demonstrate that homelessness in the United States has steadily declined over the past decade. Nevertheless, in 2015, an estimated 564,708 people were without permanent residence, 31% of whom were unsheltered (i.e., living in places not intended for human habitation; Henry, Shivji, de Sousa, & Cohen, 2015). Aggregated point-in-time count and other homelessness-related data are compiled in Annual Homeless Assessment Reports (AHARs) to Congress. Since first published in 2007, AHARs have been used to track progress on homelessness prevention and intervention programs by multiple agencies (Solari et al., 2015). It is important to note that point-in-time count data are considered somewhat inaccurate (Alacron, 2015) and thought by many working at the intersection of housing and health to be low and rough estimates.

The most recent AHAR indicated that in 2014, 1.49 million people used a homeless shelter, 19.2% of whom were in institutional settings (e.g., correctional facilities, substance abuse centers, psychiatric care facilities, or hospitals) immediately prior to entering the shelter system. Those discharged from institutional settings into an unsheltered homeless setting are not included in this number. Regardless of setting, people experiencing homelessness have high rates of physical and mental illness, increased mortality, and repeated emergency department visits and hospitalizations (Chambers et al., 2013). Health care, mental health, and correctional institutions unwittingly contribute to the revolving door of homelessness, which, in areas that lack respite or transitional care programs, often results in poor health outcomes for homeless persons and escalating costs for society (Biederman, Gamble, Manson, & Taylor, 2014). An integrated system to safely transition homeless persons back to the community from institutional settings is sorely needed.

Transitional Care

Transitional care refers to a model of care that provides a range of services aimed at ensuring health care continuity. It aims to decrease or avoid preventable adverse outcomes among at-risk populations during inevitable transitions between health care settings such as from inpatient hospital stays to outpatient clinic care. Transitional care typically focuses on highly vulnerable populations of chronically ill patients involved in critical transitions within an often fragmented health care system (Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011). Core values such as altruism, social justice, human dignity, autonomy, empowerment, and advocacy are integral to transitional care. Many effective transitional care programs are nurse-led (Naylor et al., 2011).

Nurse-led transitional care programs have demonstrated benefits including reductions in readmissions and complication-related mortality rates (Feltner et al., 2014; Solomon, Hanrahan, Hurford, DeCesaris, & Josey, 2014). Interventions employed by effective transitional care programs include comprehensive discharge planning with follow-up home visits, medication reconciliation, continuous access to health care providers via phone or Internet, and support and education for patients and their caregivers, among others. Much of the research on transitional care interventions has focused on elderly Medicare beneficiaries and on patients with specific diseases (National Health Care for the Homeless Council [NHCHC], 2012). These interventions, which are effective in decreasing adverse events after hospital discharge, generally assume and rely on the housing stability of participants and therefore may not readily transfer to the homeless population.

Homeless Medical Respite

Medical respite programs can fill the transitional care void for homeless patients being discharged from acute care settings. Medical respite care is ongoing or post-acute medical care for homeless persons who are too ill or frail to recover from a physical illness or injury on the streets but who are not ill enough to be in a hospital (NHCHC, 2014). Homeless persons are typically enrolled in or admitted to a medical respite program with the care delivered either in a stand-alone facility, shelter, or motel. The NHCHC, the preeminent national authority on homeless medical respite, maintains a directory of respite programs in the United States; in 2015, there were 73 programs listed. Medical respite programs are not just a “big city” phenomenon. Midsize cities and even smaller municipalities also benefit from homeless medical respite programs. Multiple models have been used and are often tailored to fit a community's specific needs.

Homeless medical respite programs have demonstrated positive outcomes for persons transitioning from the acute care to community setting (Doran, Ragins, Gross, & Zerger, 2013); however, limitations have been noted. Bauer, Moughamian, Viloria, and Schneidermann (2012) found that 31% of persons left a homeless medical respite program against medical advice prior to completion of treatment. In addition, not all homeless persons transitioning from an institutional setting into the community meet inclusion criteria, nor require the level of service provided by a medical respite program. CHWs represent a promising addition for effective and efficient transitional care for homeless people, both within and outside a traditional medical respite setting.

Community Health Workers

Mental health and HIV/AIDS services have long employed CHWs to enhance care for vulnerable populations. CHWs also have shown positive benefits in resource-poor international health settings. One organization, Partners in Health (PIH), has demonstrated positive outcomes including improved health and quality of life in patients with HIV served by CHWs in both rural Haiti and urban Boston (Behforouz, Farmer, & Mukherjee, 2004). In these two disparate locations, the CHW is the bridge between clinical care and the patient's lived experience. The founder of PIH, Paul Farmer, described the CHW's role as accompaniment, asserting “True accompaniment does not privilege technical expertise above solidarity or compassion or a willingness to tackle what may seem to be insuperable challenges. It requires cooperation, openness and teamwork” (Farmer, 2011, p. 41). This type of accompaniment can be life-changing both for CHWs and for care recipients. One CHW commented on this transformative process regarding one of her homeless clients as she transitioned out of homelessness and assumed an advocacy role:

The Durham County Homeless Transitions Program

With generous support from the Rita and Alex Hillman Foundation Innovations in Care Program, we are addressing homeless transitional care issues in our community through combining a nurse-led transitional care and CHW model to effectively transition homeless persons from institutional to community settings. (More information on the Hillman Innovations in Care Program can be found at http://www.rahf.org/grant-programs/hillman-innovations-in-care-program/.) Nurses are responsible for maintaining community partnerships, inviting referrals, leading monthly homeless transitional care management conferences, and assessing homeless persons experiencing institutional transitions to determine the level of care and resources needed. CHWs accompany program participants to the various service agencies identified by nursing and facilitate linkage to community-based resources. Our clients receive medication reconciliation and care coordination, assistance in navigating multiple complex systems, and connection to supportive services including primary care, mental health/substance abuse treatment, benefits assistance, and housing. The program includes a component to educate service providers on ways to optimize health and health care for individuals experiencing housing insecurity. There are also opportunities for both clients and service providers to engage in a community-based research and program evaluation intended to contribute to the homeless transitional care scientific literature base.

Conclusion

Although homelessness is decreasing in the United States, a substantial number of persons experience housing insecurity. Homeless persons suffer higher rates of morbidity than their housed counterparts and must frequently transition across institutional settings while attempting to manage chronic and/or acute illness and injury. Medical respite programs have been exceedingly successful in assisting homeless individuals during transitions from acute care facilities. A comprehensive transitional care model for homeless persons, such as the one we have begun, has the potential to dramatically improve the lives of homeless persons during transition from multiple institutional settings.