NSG/482 Week 4: Caring for People Who Are Underserved, sample paper

Nursing Care Where People Sleep Outside: A Community Practice Setting for Adults Experiencing Homelessness

[Student Name]

University of Phoenix

NSG/482: Promoting Healthy Communities

Week 4 Assignment

[Instructor Name]

[Date]

The program, clients and figures are a composite written for a model paper. No real person is described.

Most people receive health care in a building they walk into. For adults experiencing homelessness, that assumption fails at every step: they may not have a way to get to the clinic, a place to store medication or a phone to receive a reminder call. A composite city of about 400,000 people counted roughly 1,100 people experiencing homelessness on a single night last winter, about 300 of them unsheltered. The city's health care for the homeless program responds by taking nursing to where people are: a street outreach team, nurse-staffed clinics in the two largest shelters and a van that visits encampments twice a week. In this setting, the first nursing intervention is often simply being in the same place at the same time, week after week, until a person decides the nurse can be trusted. This paper describes that practice setting, the health needs of the population it serves and one change that would make its care more effective.

The Population and Its Health Burden

People experiencing homelessness in high-income countries carry a far higher burden of illness and die much younger than the general population. Fazel et al. (2014) reviewed the evidence and found high rates of infectious disease, including tuberculosis, hepatitis C and HIV, along with chronic conditions, mental illness and substance use disorders, all complicated by exposure, injury and poor access to care. Baggett et al. (2013), studying a large cohort of homeless adults in Boston, found mortality rates several times those of the general population, with drug overdose, cancer and heart disease among the leading causes of death, and overdose the leading cause among younger adults.

Those findings match what the composite program's nurses see. The most common problems at the shelter clinics are wound and foot care, uncontrolled hypertension and diabetes, respiratory infections, untreated mental illness and complications of substance use. Many clients have been hospitalized more than once in the past year, and many hospital stays end with discharge back to the street or a shelter bed that must be vacated during the day.

The Practice Setting

The program's nurses work in three settings, each with its own limits. On street outreach, a registered nurse and a peer outreach worker, who has lived experience of homelessness, walk a set route three mornings a week. They offer water, socks, wound care supplies and naloxone, perform brief assessments and invite people to the shelter clinics. At the shelters, nurses run walk-in clinics four afternoons a week, with a nurse practitioner on two of those days, and manage follow-up for chronic disease. The van brings the same services to encampments on the edge of the city.

Community-based practice here depends on flexibility more than on protocols designed for clinics. Hwang and Burns (2014), reviewing health interventions for people who are homeless, found evidence supporting approaches such as housing with support services, case management and integrated care that brings services to people rather than requiring them to find their own way through separate systems. The outreach model applies that principle: the nurse, not the client, travels.

Barriers to Care

The barriers that shape nursing care fall into three groups. Practical barriers include lack of transportation, identification documents and a phone, as well as nowhere to store medication or refrigerate insulin. System barriers include clinic hours that conflict with shelter intake times, prior experiences of being turned away or judged, and discharge plans written for people with homes. Personal barriers include untreated mental illness, substance use and understandable distrust of institutions. Each barrier suggests a nursing response. Medication can be stored at the shelter clinic and given daily. Clinic hours can match shelter schedules. The peer outreach worker can bridge the distrust that a nurse alone cannot.

Respecting Choices the Nurse Would Not Make

Street nursing constantly tests the principle of autonomy. Some clients decline shelter, decline treatment for a wound or continue to use drugs despite repeated overdoses. The program's nurses work from a harm reduction stance: they respect a client's decision, keep offering help and reduce the damage of choices they cannot change, for example by carrying naloxone, teaching safer wound care and checking back the next week. That stance is not indifference. A client who is lectured or refused care because of a choice will often stop coming, while a client whose choices are respected is more likely to accept help when he or she is ready, as the client described next eventually did.

One Composite Client

A 58-year-old man who has slept outside for three years first accepted help from the outreach team after two months of weekly contact, when the nurse cleaned a leg wound he had been treating with paper towels. He had type 2 diabetes but had stopped taking medication. Over the next weeks the shelter clinic nurse helped him obtain identification, enrolled him in Medicaid, stored his metformin at the clinic and saw him most days. His blood glucose improved. Then an infected foot ulcer led to a four-day hospital stay. He was discharged at 4 p.m. with intravenous antibiotics changed to oral, instructions to keep his foot elevated and dry and a follow-up appointment in ten days. He returned to his encampment that night. By the follow-up date the wound was worse, and he was readmitted for six days.

The discharge plan was clinically sound for a person with a home. For a man sleeping outside, it could not be followed. His case shows the gap in the program: its nurses can support clients in the community, but they cannot provide the rest and wound care that recovery after hospitalization requires.

Proposal: A Medical Respite Partnership

Medical respite care provides short-term residential care for people experiencing homelessness who are too ill or frail to recover on the street or in a shelter but do not need to be in a hospital. Doran et al. (2013), in a systematic review of medical respite programs, found evidence that respite care was associated with fewer hospital readmissions and fewer inpatient days, although the studies varied in quality. The composite program proposes a partnership with the two largest hospitals and a shelter provider to open ten respite beds in a wing of the larger shelter, staffed by nurses during the day and a shelter worker overnight.

The nurses' roles in respite would include wound care, medication administration, monitoring for complications, coordination with the client's primary care provider and planning for housing with the city's coordinated entry system. The hospitals would refer eligible patients before discharge, which also gives hospital case managers a safe discharge option for patients who would otherwise stay longer or leave to the street.

Evaluation

The program would track 30-day readmissions and inpatient days for clients referred to respite, compared with similar clients from the year before the respite beds opened. It would also track the share of respite clients who leave with a primary care follow-up completed and the share connected to housing within 90 days. Because the population is small and changes over time, the evaluation would be reported with its limits stated plainly.

Conclusion

Caring for people experiencing homelessness requires a practice setting built around their lives rather than the clinic's schedule. The composite program's outreach, shelter clinics and van bring nursing to the street, and its nurses address practical, system and personal barriers one relationship at a time. The case of one client whose hospital discharge ended in an encampment shows where that model stops working. A medical respite partnership, supported by evidence of fewer readmissions, would extend community nursing to the period when this population is most vulnerable.

References

Baggett, T. P., Hwang, S. W., O'Connell, J. J., Porneala, B. C., Stringfellow, E. J., Orav, E. J., Singer, D. E., & Rigotti, N. A. (2013). Mortality among homeless adults in Boston: Shifts in causes of death over a 15-year period. JAMA Internal Medicine, 173(3), 189-195. https://doi.org/10.1001/jamainternmed.2013.1604

Doran, K. M., Ragins, K. T., Gross, C. P., & Zerger, S. (2013). Medical respite programs for homeless patients: A systematic review. Journal of Health Care for the Poor and Underserved, 24(2), 499-524. https://doi.org/10.1353/hpu.2013.0053

Fazel, S., Geddes, J. R., & Kushel, M. (2014). The health of homeless people in high-income countries: Descriptive epidemiology, health consequences, and clinical and policy recommendations. The Lancet, 384(9953), 1529-1540. https://doi.org/10.1016/S0140-6736(14)61132-6

Hwang, S. W., & Burns, T. (2014). Health interventions for people who are homeless. The Lancet, 384(9953), 1541-1547. https://doi.org/10.1016/S0140-6736(14)61133-8