Pinkerton Capstone Total Content 3.12.2015.doc

University of Washington

Improved Patient Outcomes

Meeting the needs of homeless patients with overutilization of the ED

Jacquelyn M. Pinkerton

3/12/2015

People who are homeless have to depend on a variety of emergency services to meet their needs which has created a vicious cycle of service utilization that is difficult to break. Being homeless can create a constant state of crisis; this state of crisis is perpetuated by not being able to meet basic needs, feelings of isolation, feelings of fear, as well as compounding loss of social connections, job, and health (Clarke, Williams, Percy, & Kim, 1995). Current health systems lack services designed to meet the needs and complexity of homeless persons and this inadequacy enables the use of the emergency room as these peoples’ needs continue to go unmet (Parker & Dykema, 2013). The research indicates a need for better interpersonal, interdepartmental, and interagency collaboration to do more to increase efficacy of initial interventions and improved preventative measures to reduce unnecessary readmissions.

Pinkerton: Improved Patient Outcomes

Jacquelyn Pinkerton

Improved outcomes for homeless patients who use the ED to meet their basic needs

TSOCW 533 Advanced Integrative Practices

Teresa Holt, MSW, LICSW

March 12, 2015

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ContentsIntroduction....................................................................................................................................................4

Proposed assessment tool: Initial Encounter in ED.......................................................................................6

Subsequent Encounters..................................................................................................................................7

Supplemental Activities.................................................................................................................................8

Logic Model Template...................................................................................................................................9

Data Collection Worksheet..........................................................................................................................10

Description of Project..................................................................................................................................12

Background..................................................................................................................................................13

Risk/Priorities..............................................................................................................................................17

Bibliography................................................................................................................................................19

Problem Map................................................................................................................................................21

Force Field Analysis....................................................................................................................................22

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IntroductionI am proposing a designated position, within the hospital setting, that aims to meet the

needs of our most vulnerable patient population, namely homeless patients with high-utilization

of Emergency Department (ED) services. The short term goals are to improve patient knowledge

of community resources and improve patient access to these community resources. Looking to

the future, the long-term goal of this position is to eliminate the use of the ED by homeless

patients to meet their basic needs (eg. food, shelter, clothing, transportation etc.). These goals

necessitate that ED systems engage in interagency and interdepartmental collaborations to

connect homeless patients to providers who can meet their basic needs as evidenced by decrease

use of the emergency department. The characteristics of this proposed position include

acknowledging the dignity and worth of a person, cultivating human relationships, behaving in a

trustworthy manner, and providing services that are socially just (Martin, 2014; Parker &

Dykema, 2013; Reitz-Pustejovsky, 2002). It is important to provide real time referrals and

interventions specific to the individual being served as this approach is more effective and aligns

with NASW and agency ethical principles (Parker & Dykema, 2013).

NASW guidelines and Citizenship theory are the guiding framework for meeting the

needs of homeless patient’s utilizing the ED for non-emergencies. For these patients who are our

most vulnerable, an effective intervention must consider a theoretical framework that addresses

the relationship between justice and attachment; interventions must be meaningful for those

receiving care more than being for the person or agency offering care (Reitz-Pustejovsky, 2002).

Citizenship theory incorporates both justice and attachment by looking at the individual within

the community and whether they are represented and treated as citizens rather than being

relegated as an ‘other’. ‘Just’ care cannot be done without promoting attachment between

marginalized people and the mainstream community of which they are a part (Reitz-Pustejovsky,

2002). Citizenship theory emphasizes the agency of the individual and values the dynamic

between individual and community; when people are pushed further away from being a part of a

community they are treated as less than full citizens and subjected to subsequent injustices.

Sanabria (2006) applies attachment theory as it relates to an individual’s attachment to their

community and suggests if there is poor attachment then there are associated risks including a

minimized sense of belonging, poor outcomes for public health and increased rates of violence

and poverty. Citizenship theory reframes the conversation around homelessness by valuing the

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individual members’ and their potential contributions to society and opens the conversation to

the opportunity of community building to address a social issue (Reitz-Pustejovsky, 2002).

Finally, citizenship theory also provides a framework for treating within a psycho-social context

(Rowe, Kloos, Chinman, Davidson, & Cross, 2001). By operating within this framework we will

address the strengths and needs of the individual while collaborating with the larger community

to improve outcomes.

By implementing a designated position to facilitate continuity of care following ED

discharge, the anticipated outcomes include improved patient knowledge of community

resources and improved patient access to services. An assumption of this proposal is that

homeless patients are brought to the ED, voluntarily or involuntarily, because they have basic

needs that are not being met in the community. By utilizing the designated case worker in real

time we can identify the most emergent needs and actively implement referrals rather than

provide patients with a handful of generic resources and send them on their way. In addition to

the direct services provided to patients, this position must also cultivate and maintain community

partnerships to ensure a smooth transition for referrals. When providers collaborate, rather than

operate siloed within their agency, they can more effectively meet the needs of the patient by

mitigating the risk of losing them in the transition and also by reducing inefficiencies of

duplicative work inherent in repeat data collection. In addition to the individual patient outcomes

this intervention will also free up ED beds, provide cost savings to the hospital by reducing

readmission of patients whose services may not be reimbursable, and improve relationships with

community partners who can meet the needs of these patients in an outpatient community

setting.

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Proposed assessment tool: Initial Encounter in EDEncounter Date: Record the date of first encounter with patient

Patient Name: Lat name, First Name Patient Number: System generated patient ID #

Means of Arrival: Indicate how the patient arrived in the ED at current encounter. Consider looking at previous ED admissions and patient means of arrival, this may inform subsequent intervention as it relates to barriers and indicated (in)voluntary use of ED.

Presenting Problem: Record the presenting problem upon arrival.

Secondary Problem(s): Ask the patient if there are additional problems not addressed in previous section.

Patient Goals for Treatment: What are the patient’s treatment or outcome goals. Is the patient amenable to service/intervention?

Needs or Barriers: Indicate patient self-reported needs or barriers preventing access to services or treatment. Case Worker can infer additional items but should validate with patient for accuracy.

Mental Health Services

Case Management Counseling Rx Management

Medication Prescriber Access Coverage Management

Food Food Stamps Local Food Banks Hot Meal providers

Shelter Case Management Physical Shelter

Transportation Bus Pass Taxi Scrips Gas Card

Communication Telephone Voicemail Email Mailing Address

Storage

Other, specify

Strengths and Informal Supports: Identify patient strengths and informal supports available to meet identified goals.

Case Manager

Family, friends

Spiritual Congregation

Community Group

Support Group

Other, specify

Next Steps: What are the next steps within the 1st week of encounter. How will Case Worker and patient reconnect?

Subsequent EncountersWithin 7 days of initial ED Encounter.

Review Initial Assessment Make adjustments to action plan and implement identified next steps.

Implement action plan within first 30days. Ensure that patient has made connections with community service providers or identified case managers.

Follow-up with patient at 3/6/12 month intervals to monitor progress and facilitate ongoing implementation of plan. Make changes to the plan as needed based on patient’s changing psycho-social context, survey responses, and 1:1 interview.

Administer survey prior to face to face and discuss during appointment.

1. What are your needs (for example: shelter, food, personal hygiene, clothing, storage, telephone/internet, transportation, medical follow-up, dental, counseling, employment services, case management)

a. _____________b. _____________c. _____________

2. Where can you go to meet the needs you listed?a. _____________b. _____________c. _____________

3. Who can you contact to attain resources?a. _____________b. _____________

4. Who can help you attain community resources if you are unable to access them independently? ____________________________________________________________________________

Interview: Review action plan established at initial intake. Discuss patient gaps in knowledge about their individual action plan. Ask patient if their needs are being met.

Case Records: Review hospital EDIE report and patient encounter record. Discuss outcomes or record with patient during interview.

1. Made necessary appointment (indicate type of services):a. Service __________________Appointment Date _______________ Attended/Missed

i. Reason missed(if applicable) _________________________________________b. Service __________________Appointment Date _______________ Attended/Missed

ii. Reason missed(if applicable) _________________________________________c. Service __________________Appointment Date _______________ Attended/Missed

iii. Reason missed(if applicable) _________________________________________


Supplemental ActivitiesEstablish and maintain Memorandums of Understanding (MOUs) with community partners. MOUs to be established with community providers who provide services relevant to our target population.

Work with IT Specialist to improve resource database; monitor accuracy of database on a monthly basis to ensure efficient referrals.

Meet with community partners quarterly to discuss what is working in the referral process and identify areas for improvement.

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Logic Model TemplateNeeds Statement: ED systems need to engage in inter-agency/interdepartmental collaborations to connect homeless patients to providers who can meet their basic needs as evidenced by decrease use of the emergency department.Theoretical Influences and Assumptions: Citizenship theory is the guiding framework for meeting the needs of homeless patient’s utilizing the ED for non-emergencies. This theory emphasizes the agency of the individual and values the dynamic between individual and community. By operating within this framework we will address the strengths and needs of the individual while collaborating with the larger community.

RESOURCES

ACTIVITIES

(Process Objectives)

OUTPUTS*

(Outcome/Summative Objectives)

OUTCOMES

(Short term goals)

*OUTCOME

INDICATORS (Outcome/Summative

Objectives)

LONG TERM GOAL

Funding for new

position Funds to invest

in possible community placement or referral settings (designated beds or one night stays)

Agency vehicle to provide client transportation or mileage reimbursement

Tech support and updated resource list

Create

Memorandums Of Understanding (MOU) with partner agencies

Maintain partnerships with MOU’s

Develop initial process with case worker for referral

Case worker ensures follow-up with community agency

Hospital designated case worker

Improved database with map of community resources

MOU’s with

shelter/food/resource providers within the Auburn community

Quarterly roundtable with partners to address service referral issues

Increase meeting of patient’s basic needs through effective referral process and action plan

Free up ED beds Online interactive

resource map

Outcome 1: Improved knowledge of community resources.

Outcome indicator 1a: Knows who to contact to attain community resources. Outcome indicator 1b: Knows how to get community resources.

The long-term goal is to eliminate the use of the Emergency Department by homeless patients to meet their basic needs (eg. Food, shelter, clothing, transportation etc.)

Outcome 2: Improved access to services

Outcome indicator 2a: Accesses services that meet needs. Outcome indicator 2b: Implements action plan to meet service needs with other community resources.


Data Collection Worksheet

OUTCOMES/CRITERIA TOOLSDATA

COLLECTION PROCESS

DATA COLLECTION

METHODVALIDITY

Outcome 1: Improved knowledge of community resources. Criteria: Patient has achieved outcome indicators 1a and 1b. Outcome indicator 1a: Knows who to contact to attain community resources. Criteria: Patient can identify their needs and appropriate resources to meet those needs on a survey. Outcome indicator 1b: Knows how to get community resources. Criteria: Patient is able to indicate on the survey how to access services to meet their basic needs.

Outcome 1 Tool:Survey: Objective measurement of whether patient possesses the knowledge that indicates progress or competence.

Collected at initial appointment and final appointment.

Gather data on all clients.

Peers and key stakeholders are able to identify the purpose of the questions being asked

Participants respond appropriately

Participants consistently respond appropriately

Data supports participant responses

Outcome 2: Improved access to services. Criteria: Patient has achieved outcome indicators 2a and 2b.Outcome indicator 2a: Accesses services that meet needs. Criteria: Patient is able to self-report where there needs have been met and there will be a decreased incidence of ED utilization.Outcome indicator 2b: Implements action plan to meet service needs with other community resources. Criteria: During interview patient can articulate the action plan and whether that plan has led to their basic needs being met.

Outcome 2 Tool: Interview with patients: Their subjective understanding of behavior competence. Case Records: Objective tool to evaluate patient’s previous use of inappropriate services compared to current use of appropriate services.

Case worker collects this information at final appointment and then 3/6/12 month follow-up intervals.

Check ED reports. Provide case worker contact information to patients and encourage patient to

RELIABILITY

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Outcome 1: Improved knowledge of community resources. Outcome indicator 1a: Knows who to contact to attain community resources. Criteria: Patient can identify their needs and appropriate resources to meet those needs on a survey. Outcome indicator 1b: Knows how to get community resources. Criteria: Patient is able to indicate on the survey how to access services to meet their basic needs.

Survey (administer survey prior to face to face and discuss during appointment)

5. What are your needs (for example: shelter, food, personal hygiene, clothing, storage, telephone/internet, transportation, medical follow-up, dental, counseling, employment services, case management)

a. _____________b. _____________c. _____________

6. Where can you go to meet the needs you listed?a. _____________b. _____________c. _____________

7. Who can you contact to attain resources?a. _____________b. _____________

8. Who can help you attain community resources if you are unable to access them independently? ____________________________________________________________________________

Outcome 2: Improved access to services. Outcome indicator 2a: Accesses services that meet needs. Criteria: Patient is able to self-report where there needs have been met and there will be a decreased incidence of ED utilization. Outcome indicator 2b: Implements action plan to meet service needs with other community resources. Criteria: During interview patient can articulate the action plan and whether that plan has led to their basic needs being met.

Interview: Review action plan established at initial intake. Discuss patient gaps in knowledge about their individual action plan. Ask patient if their needs are being met.

Case Records: Review hospital EDIE report and patient encounter record. Discuss outcomes or record with patient during interview.

2. Made necessary appointment (indicate type of services):a. Service __________________Appointment Date _______________ Attended/Missed

iv. Reason missed(if applicable) _________________________________________b. Service __________________Appointment Date _______________ Attended/Missed

v. Reason missed(if applicable) _________________________________________c. Service __________________Appointment Date _______________ Attended/Missed

vi. Reason missed(if applicable) _________________________________________

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Description of ProjectThe following proposal is a micro-level intervention aimed at serving homeless

patients who over utilize the hospital Emergency Department (ED) to meet their basic needs.

This intervention requires a designated case worker who can meet patients where they are at,

conduct a holistic psycho-social assessment to identify their strengths and needs, develop an

individual action plan, connect these patients with providers in our community for ongoing

support, and provide follow-up to ensure successful implementation of their individual action

plans. Not only will this proposed intervention improve outcomes for the patients being

served but it will reduce fiscal losses incurred by the hospital for rendering services that may

or may not be reimbursed. Over-utilization of the ED by patients, specifically homeless

patients, requires an intervention that connects the individual to the larger community in

order to break the cycle of: ED utilization for immediate crisis relief, rapid discharge, and

subsequent return to the ED.

Our target population consists of those patients who are repeatedly admitted to the

ED because their basic needs are not being met in the community. Basic needs may include

shelter, food, security, stability, medical, and/or mental health treatment. Some of these

patients come to the ED voluntarily while others are brought to the ED involuntarily. For

these patients who are our most vulnerable, an effective intervention must consider a

theoretical framework that addresses the relationship between justice and attachment.

Interventions must be meaningful for those receiving care more than being for the person or

agency offering care (Reitz-Pustejovsky, 2002). Citizenship theory incorporates both justice

and attachment by looking at the individual within the community and whether they are

represented and treated as citizens rather than being relegated as an ‘other’. ‘Just’ care cannot

be done without promoting attachment between marginalized people and the mainstream

community of which they are a part (Reitz-Pustejovsky, 2002). Citizenship theory

emphasizes the agency of the individual and values the dynamic between individual and

community; when people are pushed further away from being a part of a community they are

treated as less than full citizens and subjected to subsequent injustices. When trying to meet

the needs of those being served it is unjust to leave them out of the conversation because they

do not have the economic privilege to interject themselves into the conversation (Sanabria,

2006). Sanabria (2006) applies attachment theory as it relates to an individual’s attachment to

12


their community and suggests if there is poor attachment then there are associated risks

including a minimized sense of belonging, poor outcomes for public health and increased

rates of violence and poverty. Citizenship theory reframes the conversation around

homelessness by valuing the individual members’ and their potential contributions to society

and opens the conversation to the opportunity of community building to address a social

issue (Reitz-Pustejovsky, 2002). Finally, citizenship theory can also provide a framework for

treating within a psycho-social context (Rowe, Kloos, Chinman, Davidson, & Cross, 2001).

I propose that we allocate resources for a designated case worker to meet the

individual needs of our target population that allows for continuity of care following

discharge therefore improving outcomes and reducing overall costs to the hospital. This case

worker would have improved access to resource database information and be responsible for

maintaining memorandums of understanding (MOU’s) with partner agencies to facilitate

implementation of patient’s individual action plans. Anticipated outcomes of this

intervention include better outcomes for our patients, freeing up ED beds, and cost savings to

the hospital by reducing readmission of patients whose services may not be reimbursable. We

will also have improved relationships with community partners who can meet the needs of

these patients outside the scope of services available in the ED.

Values and ethical considerations guiding this intervention include acknowledging

the dignity and worth of a person, cultivating human relationships, behaving in a trustworthy

manner, and providing services that are socially just (Martin, 2014; Parker & Dykema, 2013;

Reitz-Pustejovsky, 2002). It is important to provide real time referrals and interventions

specific to the individual being served as this approach is more effective and aligns with

NASW and agency ethical principles (Parker & Dykema, 2013).

BackgroundThe needs identified to address the problem of overutilization of the ED for non-

emergencies include needed resources and changes in ED practice. Resources that are needed

include tools for service providers to more efficiently identify/organize what is available to

meet patients’ needs within the context of their own limitations. Hospital organizations could

utilize fiscal resources to reserve crisis beds and/or fund community shelters to increase

capacity in the community and decrease reliance on ED beds. Without necessarily putting

money directly into the community, organizations may benefit from having a staff person

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who specializes in knowing what resources are available and maintaining MOUs with those

providers. There is a need for someone to be available outside of normal business hours to

implement intervention and prevention strategies for ED high-utilizers. This designated role

could address emergency and long-term intervention needs for the including care

coordination, supporting those most at risk, and strengthening relationships between agencies

(Kutza & Keigher, 1991). Outreach is important component to meet the needs of a population

that faces barriers as ‘simple’ as a front door (Martin, 2014; McDougal-Treacy, 2014).

Finally, there is a need to break down the barriers that lead to providers working within

individual silos thus reducing the efficacy of care and collaboration. Applebee (2014)

discussed the challenges of effective intervention in the emergency rooms because medical

staffs have a priority to meet the emergency medical needs of patients and this requires that

referrals be made to other ED staff for ongoing follow-up or intervention. While it makes

sense that medical staffs do not have the time to do individual intervention there is room for

improvement as far as collaboration between roles and effectively meeting the patients’

needs. Increased collaboration in connecting homeless patients with community providers is

a potential need due to a common misperception that homeless people are especially mobile

and not likely to follow-up with outpatient care (Parker & Dykema, 2013).

Homelessness is not a new issue and it impacts readmission rates within emergency

departments by the chronically ill and mentally ill due to an ongoing lack of adequate

community supports and shelter (Rosenfield, 1991). Homelessness has and continues to

evolve based on changing social and economic climate. For example, in the 1980’s there was

a social and political shift that resulted from unintended consequences of

deinstitutionalization of the mentally ill, ‘War on Poverty’, and establishment of minimum

wage (Clarke, Williams, Percy, & Kim, 1995). These social policy changes were designed to

reintegrate the mentally ill into the community, establish a safety net, and combat a social

issue that had a resurgence of public visibility and attention. Deinstitutionalization was

especially detrimental in that it took away basic needs like shelter, regularly scheduled meals,

accessible mental health and medical providers, and stability without creating community

supports to provide continuing care (Kutza & Feigher, 1991; Rosenfield, 1991). Socially

there is a general consensus that the issue of homelessness requires intervention but as a

collective we lack the conviction to hold ourselves accountable to meeting this need.

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Homeless people are a vulnerable population and those with the social and political power

have a responsibility to advocate for justice on behalf of those without power (Reitz-

Pustejovsky, 2002). In addition to our social responsibility to address the problem of

homelessness we also need to change our attitudes towards the homeless population. We

create artificial standards for those who are deserving of help, like veterans, women and

children, and those who are undeserving like men, immigrants, and drug addicts; these

artificial lines blur our vision and treatment of these people and create unnecessary hurdles in

trying to initiate change. Trying to judge those deemed unworthy and mandating that they

change their individual behaviors isolates them from mainstream society thus perpetuating

stigma and a cycle of victim blaming (Laakso, 2013).

Regardless of the time period, some similarities identified in the past and present

homeless populations include extreme poverty, mental illness and/or chemical dependency,

physical disability, social isolation, and reliance on shelters, food banks, community health

clinics, and clothing banks to meet their basic needs (Rossi, 1990). This population has to

depend on a variety of emergency services to meet their needs and it has created a vicious

cycle of service utilization that is difficult to break. Being homeless can create a constant

state of crisis as individuals are unable to cope as a result not knowing how they are going to

meet their most basic needs, feelings of isolation, feelings of fear, as well as compounding

loss of social connections, job, and health (Clarke, Williams, Percy, & Kim, 1995).

Homelessness is perpetuated by a culmination of relatively ‘minor’ setbacks that reinforce an

individuals’ need to ‘just’ survive not allowing them to ever get ahead (Clarke, Williams,

Percy, & Kim, 1995). Socially we need to support these people and implement a system that

facilitates real change rather than ad-hoc or short-term temporary fixes.

Contributing research interventions presently identified in the literature include

psychosocial assessments to determine individual needs, outreach teams to address barriers to

care compliance, reducing barriers faced by homeless patients, utilizing outpatient referral

resources, improved continuity of care, and involving the community. Conducting a needs

assessment is important within micro level interventions as it will inform subsequent

intervention and supports the value of meeting each person where they are and not

compromising that interaction by trying to pull them out of their context and imposing

dominant ideas of what is best (Kutza & Keigher, 1991). Outreach teams can also reduce

15


barriers faced by homeless patients’ as it relates to transportation needs or forcing them to

prioritize preventative care and meeting their basic needs for survival (McDougal-Treacy,

2014). Sanabria (2006) discusses how lack of coordination can make subsequent

interventions ineffective. Rosenfield (1991) also discusses ongoing contact and continuity of

care positively impacting patient outcomes by reducing utilization of the emergency room for

non-emergencies. Parker and Dykema (2013) found in their research that providers who

practiced active referrals to outpatient sources saw better outcomes, for example reduced

emergency room visits, than providers who discharged patients with directions along the idea

of ‘If symptoms get worse come back.’. For those who are homeless they face social barriers

that perpetuate marginalization and make it more difficult to improve their situation (Laakso,

2013). Martin (2014) suggests that service providers can better serve this population by

reducing burnout among providers so they can provide a good experience to service

recipients that encourages them to seek help, reducing material barriers or help people

overcome material barriers such as requirement of identification or a mailing address, value

individuals’ need for self-efficacy and self-esteem, and build human relationships that reduce

the separation of patient and professional. Assertive Community Treatment (ACT) teams are

another possible intervention that was mentioned in the literature as possibly effective

intervention. ACT teams have been found to reduce the negative impact of staff turnover,

thus supporting continuity of care, and may address the challenges associated with care non-

compliance as a result of choice or addressing barriers to full participation (Bond, et al.,

1991; Rowe, Kloos, Chinman, Davidson, & Cross, 2001). ACT teams work from a strengths

based perspective, address patient identified needs, and provide a stable foundation for

ongoing treatment (Rowe, Kloos, Chinman, Davidson, & Cross, 2001). Dubose (2014) was

able to share information related to the Ambulatory Care Coordination Team (ACCT)

implemented by Multicare that is similar to ACT teams and has potential applications beyond

the population it is currently serving. The ACCT currently serves patients who are high

utilizers of inpatient services, through referrals from Multicare Staff, by providing

intervention to improve self-management and improve health outcomes. This team could be

expanded to intervene in the ED prior to inpatient hospitalizations and could expand meet the

needs of our homeless patients who are high utilizers by helping them connect to services

and support follow-up with their care providers.

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After consideration of the current research and discussions with key informants, there

is a gap in the current hospital setting as it relates to effectively meeting the needs of our

homeless patients who are high-utilizers of the ED. Having a designated role or staff to

develop and maintain MOUs that facilitate prevention, crisis intervention, and continuity of

care would be a valuable additional to our intervention strategies. Socially, and as an agency,

we are falling behind in addressing the needs of this vulnerable population and it would be in

our best interest to take the time now to implement effective solutions rather than waiting

until the problem reaches a crisis level that becomes subjected to additional mandates from

external entities and public policies. The research indicates a need for better interpersonal,

interdepartmental, and interagency collaboration to do more to increase efficacy of initial

interventions and improved preventative measures to reduce unnecessary readmissions.

Risk/PrioritiesBy implementing this proposal our agency will benefit from financial savings,

possible future funding opportunities, better patient outcomes, and improved connectedness

with the community. There is no denying that the funding structure for healthcare is

changing. Policy makers and funders are shifting towards outcome based compensation and

we have an opportunity to implement interventions now that will better position our agency

to maintain funding streams in the future. This intervention mandates maintenance of

community partnerships that will serve our agency better as we can utilize one another’s

resources in order to most effectively meet the needs of our patients rather than having the

patients overly rely on an emergency system that can only defer to community providers

nonetheless. In addition to more effectively using resources that currently exist in the

community we also build social capital with our partners and key stake holders who will

have a vested interest in the success of our facility.

This intervention is highly feasible as it draws from roles and programs that already

exist within our agency. Our Social Workers, Care Managers, and ACCT all have

components of the proposed intervention but no single role has been able to effectively meet

the need of this vulnerable patient population. Potential barriers include navigating the

boundaries between this proposal and the current system as well as identifying the extent of

the need and how this position will most effectively serve our multiple locations. This project

will most effectively be implemented as a pilot project that initially focuses on establishing

17


MOU’s and developing the resource database then gradually starts accepting referrals to

begin the proposed intervention. Potential liabilities include those incurred by having staff

working in the field rather than strictly within the hospital, providing transportation to

patients in private vehicles, and making sure that the intervention does not supplant resources

available through community partners or appropriate hospital staff.

Political interest in the homeless population and what kind of services should be

available to them has varied over time. Despite heightened public awareness of homelessness

as a social problem we still see the general public and policy makers acting on ideas that

people in poverty are there as a result of their individual characteristics without consideration

of the systemic or cultural context within which they became homeless (Laakso, 2013).

Within the ED, patients who are homeless may be treated differently regardless of whether

their presenting problem is shelter-seeking, a result of complications of drug abuse, active

psychotic symptoms, or a legitimate medical emergency; this variance is an example of our

cultural attitudes where the quality of care that is delivered depends on whether you are

deemed worthy to receive it. Although there is still social bias related to the issue of

homelessness it is still omnipresent throughout political conversations from the local through

the Federal levels of government. Through the current discourse we have an opportunity to

effect change and participate in the conversation while meeting the needs of our patients and

our agency.

Within our agency there will be limited policy changes as we define the role and

scope of this intervention and incorporate it into the current structure. We will need to

consider the system as it presently exists and may need to negotiate aspects that overlap with

current departments or roles.

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illness and citizenship. Social Policy and Administration, 35(1), 14-28.

Sanabria, J. J. (2006). Youth homelessness: Prevention and intervention efforts in psychology.

Univeritas Psychologica, 5(1), 51-67.

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Homeless people’s needs are met

No improvement of problem intensity

Elimination of the problem

a i n i n g F o

i n g F o r c e

Federal Mandate- MnKinney Vento Act

Increased public awareness of causes of homelessness

Local efforts to create safe spaces (ie Safe Parking Program in Seattle, encampments on private property)

Affordable Healthcare

211 information center to locate food banks and other services or essential needs

Programs focused on community stabilization as a preventative or transition service

Increased accessibility of information through internet search and interagency collaboration

Programs that provide community voicemail or free phones

Daytime services to meet hygiene needs Vocational

rehab services

Funding priorities depend on trending issues

A practice of “other-ing” or society not wanting to acknowledge problem

Communities pushing out undesirable set-ups (ie tent cities, low barrier housing, shelters, methadone clinics)Lack of funding for

alternative housing options

Providers not wanting to be reimbursed at lower rates (Medicaid patients or Section 8 tenants)

Unstable employment

Barriers to getting needing identification to obtain services

Programs favoring “certain types of homelessness” ie families, people with cars, people who can speak English

Migration of individuals following available resources

Instability of access to available resources (like transportation needs)

Problem Map


22

Homeless overutilization of the ED for non-emergencies

Inadequate system response to homelessness

Gaps in service continuum (housing, healthcare, mental health treatment, education, employment support, etc.)

Funding issues/ inadequate funding

“We do enough for them”

Homeless people have nowhere else to go

Existing services are exhausted

Not a funding priority because “they made their bed they can lay in it”

Involuntary Admit

Private behaviors acted out in a public space

Limits on utility of public space

Civil detention expectations for individuals who violate social expectations of appropriate use of public space

“Not in my backyard” “Keep them out of sight

Voluntary admit

Socialized to seek care of ED

Lack of alternative resources

Providers not willing to take new patients that can be billed/reimbursed at a lower rate

Person(s) left without medications, food, shelter, other basic necessities

Person(s) feeling without hope or devalued

Person(s) may engage in maladaptive coping

Desperation

Learn what to say to survive; exhibit problem behaviors, make false claims; play into socially expected behavior (“act crazy” state SI/HI)

Get to stay, basic needs met

Reinforcement of ED Utilization

Loss of individual choice until deemed safe to go

If deemed unsafe then referred to involuntary psych placement

If detained possible loss of citizenship rights

Less self-esteem and les self-determination

Less motivation to be productive

Resentful or antisocial

“I need/ seek help”

Recognized need exists

I’m of no value” “I’m angry”

Force Field Analysis

Pinkerton Capstone Total Content 3.12.2015.doc

Documents

Transcript of Pinkerton Capstone Total Content 3.12.2015.doc