DOES A CASE MANAGEMENT APPROACH IMPROVE HEALTH OUTCOMES FOR HOMELESS PEOPLE?

Staci Leyko, RN Ferris State University NURS 450

Homelessness Homelessness is defined as: “an individual who lacks housing (without

regard to whether the individual is a member of a family) including an individual whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations, and an individual who is a resident in transitional housing”

National Health Care for the Homeless Council (NHCHC). (2014). What is the official definition of homelessness? Retrieved from http://www.nhchc.org/faq/official-definition-homelessness/

Examples of Homeless People People living in shelters, including

domestic violence shelters Incarcerated individuals Families who lost their home to foreclosure

and are living with other family members People living in their cars

Do you know anyone who is homeless based on the definition???

National Homeless Statistics It is difficult to count the number of

homeless people in any given community, let alone the nation.

The number of homeless persons surged in the 1980’s Cuts in housing and social services Aftereffects of deinstitutionalization Deteriorating economyZlotnick, C., Zerger, S., & Wolfe, P.B. (2013). Health care for the homeless: What we have learned in the past 30 years and what’s next. American Journal of Public Health, 103, S199-S205. doi: 10.2105/AJPH.2013.301586

National Homeless Statistics

There are a total of 1,750,000 homeless people in the US 44% of them are single men 13% of them are single women 36% of them are families with children 7% of them are unaccompanied minors

Statistic Brain. (2013). Homelessness/Poverty stats. Retrieved from http://www.statisticbrain.com/homelessness-stats/

National Homeless Statistics Of the 1,750,000 homeless people in the

US 50% of them are African American 35% of them are White 12% of them are Hispanic 2% of them are Native American 1% of them are Asian

Statistic Brain. (2013). Homelessness/Poverty stats. Retrieved from http://www.statisticbrain.com/homelessness-stats/

Michigan Homeless Statistics In 2011, there were 94,033 homeless

people in Michigan Upper Penninsula-2,356 homeless people Northern Lower Penninsula-4,420 homeless

people West Central-10,281 homeless people East Central-3,256 homeless people Thumb-4,745 homeless people South West-9,228 homeless people South Central-11,876 homeless people Detroit Metro Region-27,515 homeless

people

Michigan Homeless Statistics The number of homeless families in

Michigan dropped by 8.7% in 2011 Still 50% of the homeless population in

Michigan consists of adults and children in families

51% of those families were first-time homeless

The remaining 50% tend to be middle-aged and older males with significant disabilitiesMichigan’s Campaign to End Homelessness. (2012). Coming home: The campaign to end homelessness synopsis. Retrieved from http://www.thecampaigntoendhomelessness.org/LinkClick.aspx?fileticket=chaQ9EMQ1e0%3d&tabid=68

Peplau’s Theory of Interpersonal Relations

Graduated from Pottstown, PA school of nursing in 1931

Bachelor’s Degree in Interpersonal Psychology in 1943

Master’s and Doctoral Degrees from Teacher’s College, Columbia University

1950’s she created and taught the first classes for graduate nursing students at Teacher’s College

Nursing Theory. (2013). Hildegard Peplau-Nursing Theorist. Retrieved from http://nursing-theory.org/nursing-theorists/Hildegard-Peplau.php

Peplau’s Theory of Interpersonal Relations

Studied psychological issues at Chestnut Lodge-a private psychiatric facility

Served as an Army Corps nurse Advisor to the World Health Organization Consultant to US Surgeon General, US Air

Force, and the National Institute of Mental Health

Participated in policy-making groups for the US government

Nursing Theory. (2013). Hildegard Peplau-Nursing Theorist. Retrieved from http://nursing-theory.org/nursing-theorists/Hildegard-Peplau.php

Peplau’s Theory of Interpersonal Relations

Includes 7 nursing roles which can be applied in different situations

“Ensures that patients receive the best care possible, and will ultimately speed along treatment and recovery”

Role 1-stranger-nurse receives the patient the way the stranger is met in other situations, provides an atmosphere to build trust

Role 2-resource role-nurse answers questions, interprets data, and gives information

Peplau’s Theory of Interpersonal Relations

Role 3-teaching role-nurse gives instructions and provides training

Role 4-counseling role-nurse helps the patient understand the meaning of current circumstances, as well and provides guidance and encouragement for change to occur

Role 5-surrogate role-nurse acts as an advocate on behalf of the patient

Role 6-active leadership role-nurse helps the patient take responsibility for meeting treatment goals

Peplau’s Theory of Interpersonal Relations

Role 7-technical expert-the nurse provides physical care for the patient and operates equipment

Nurses can use each of the 7 roles to aid in treating the homeless person and assist in improving the health outcomes of the homeless

Nursing Theory. (2013). Hildegard Peplau-Nursing Theorist. Retrieved from http://nursing-theory.org/nursing-theorists/Hildegard-Peplau.php

Maslow’s Hierarchy of Needs

Psychological Theory identifies 5 levels of need

Concept introduced in 1943 Most often displayed as a pyramid

Levels of the pyramid are displayed with the most basic needs on the bottom and the more complex needs toward the top

Once the basic needs are met, people can move up to the next level of needs

Cherry, K. (n.d.). Hierarchy of needs: The five levels of Maslow’s hierarchy of needs. Retrieved from http://psychology.about.com/od/theoriesof personality/a/hierarchyneeds.htm

Maslow’s Hierarchy of NeedsPyramid image of Maslow’s Hierarchy of Needs

Maslow’s Hierarchy of Needs Level 1-Physiological Needs-includes the

most basic needs that are vital to survival

Level 2-Security Needs-includes needs for safety and security

Level 3-Social Needs-includes need for belonging, love, and affection

Level 4-Esteem Needs-includes need for things that reflect self-esteem, personal worth, social recognition, and accomplishment

Maslow’s Hierarchy of Needs Level 5-Self-actualizing needs-includes needs

for self-awareness, concern for personal growth, less concerned with opinions of others, and interest in fulfilling potential

The Maslow’s Hierarchy of Needs Theory can be applied to treating the homeless starting with the basic physiological needsCherry, K. (n.d.). Hierarchy of needs: The five levels of Maslow’s hierarchy of needs. Retrieved from http://psychology.about.com/od/theoriesof personality/a/hierarchyneeds.htm

Root Cause Analysis What causes homelessness?

Injury or illness-leads to time off work, lack of ability to perform work functions, leads to loss of employment and income, loss of health insurance

Inadequate Health Insurance-people do not have enough resources to pay for health services on their own

Crisis Poverty-lack of employment opportunities, obsolete job skills, lack of education, domestic violence

Root Cause Analysis What causes homelessness continued?

Family estrangement-unable to depend on family members for basic needs

Alcohol and drug abuse-spending income of supporting disease

Poor social skills-unable to seek out help from others, afraid or embarrassed to be around other people

Mental and physical disability-not enough facilities for treatment

Gerber, L. (2013). Bringing home effective nursing care for the homeless. Nursing 2013, 43(3), 32-38. doi: 10.1097/01.NURSE.0000426620.51507.0cNational Health Care for the Homeless Council (NHCHC). (2011). Homelessness & health: What’s the connection? Retrieved from http://www.nhchc.org/wp- content/uploads/2011/09/Hln_health_factsheet_Jan10.pdf

Policies and Resources Patient Protection and Affordable Care Act McKinney-Vento Homeless Assistance Act Women, Infants and Children (WIC) program HEARTH Act of 2009 Nurse Managed Health Clinics Heartside Clinic in Grand Rapids, MI Bell Building Project in Detroit, MI

Locally-Sparrow Hospital VOA clinic opens on 3/3/14-only the second of its type in the nationGerber, L. (2013). Bringing home effective nursing care for the homeless. Nursing 2013, 43(3), 32-38. doi: 10.1097/01.NURSE.0000426620.51507.0c

Implications on Health Physical Health Implications

Prevalence of illness in homeless persons is as high as 55%

Life expectancy of homeless is an average of 44 years, compared to 78 years for the general US population

Higher rates of chronic disease-most homeless people have at least one chronic disease

29% have hypertension compared to 16.5% of the general population

Implications on Health Physical Health Implications continued

Chronic conditions common in the homeless population include: hypertension, diabetes, asthma, liver conditions, HIV/AIDS, kidney disease, pneumonia

Exposure to communicable diseases such as TB, respiratory illness

Malnutrition Harmful weather exposure-leads to

frostbite or dehydration

Implications on Health Physical Health Implications continued

Poor dentition, toothless Lack of access to medications Lack of places to store medications Skin conditions due to lack of shelterNational Health Care for the Homeless Council (NHCHC). (2011). Homelessness & health: What’s the connection? Retrieved from http://www.nhchc.org/wp- content/uploads/2011/09/Hln_health_factsheet_Jan10.pdfSavage, C., & Lee, R.L. (2010). Caring for a homeless adult with a chronic disease. American Nurse Today 5(3). Retrieved from http://www.americannursetoday.com/article.aspx?id=6376

Implications on Health Psychological Health Implications

37% of homeless report depression compared to 10% of general US population

As many as 84% of homeless men and 58% of homeless women have alcohol problems

Embarrassment about hygiene and appearance High Stress Levels 20-25% have some form of mental illness

including: bipolar disorder, dementia, depression, personality disorder, PTSD, schizophrenia

Gerber, L. (2013). Bringing home effective nursing care for the homeless. Nursing 2013, 43(3), 32-38. doi: 10.1097/01.NURSE.0000426620.51507.0cNational Coalition for the Homeless. (2009). Health care and the homeless. Retrieved from http://www.nationalhomeless.org/factsheets/health.html

Implications on Health Social Health Implications

Perception of disturbing in waiting rooms Poor education leads to homeless unsure if able to

complete forms properly Unsure of where to turn for help Embarrassment due to appearance and personal

hygiene Self-survival, only rely on oneself Literacy difficulties Alienation from the healthcare systemGerber, L. (2013). Bringing home effective nursing care for the homeless. Nursing 2013, 43(3), 32-38. doi: 10.1097/01.NURSE.0000426620.51507.0c

Implications on Health Community Health Implications

Increased financial strain Lack of resources for treatment Lack of affordable housing Exposure to communicable diseases Increased violence Poor morbidity and mortality statistics

Quality and Safety Improvements

Case Management Approach Case management is defined as “a

collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes”.

Case Management Society of America (CMSA). (n.d.). What is a case manager? Retrieved from http://cmsa.org/Home/CMSA/WhatisaCaseManager/tabid/224/Default/aspx

Quality and Safety Improvements

Case Management Approach Case management coordinates services

between and with other organizations, advocates for key services, and provides direct support to ensure necessary care

Addresses the well being and quality of life as that person defines it, not as defined by diagnostic categories

Health care systems become more responsive and relevant

Quality and Safety Improvements

Case Management Approach Create a continuum of care with fewer barriers

between agencies Brings health care system to the client, rather than

asking the client to find it Process includes identifying cases, identifying

problems, planning and projecting outcomes, implementation, evaluation, and documentation

One Stop Shopping-builds trust, only need to go to 1 service provider

Hoonk, J. (2007). Case managing the homeless and the role of community health workers. Retrieved from http://allnurses.com/general-nursing-discussion/case- managing-homeless-265503.htmlZlotnick, C., Zerger, S., & Wolfe, P.B. (2013). Health care for the homeless: What we have learned in the past 30 years and what’s next. American Journal of Public Health, 103, S199-S205. doi: 10.2105/AJPH.2013.301586

QSEN Competencies 1. Patient Centered Care-the patient is at the

center of care. The plan of care is developed around the patient’s individual needs.

2. Teamwork and Collaboration-the patient and the case manager must work together and with available resources to meet the needs to the patient

3. Safety-the patient must have a plan developed that promotes individual and community safety in mind

ANA Standards ANA Standard 3-Outcomes Identification

The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation

This standard is very relevant in caring for the homeless. The outcomes must be realistic and resources must be available to allow the homeless person to complete the outcome. The situation relative to housing, finances, transportation, insurance, etc. must be taken into account.American Nurses Association (ANA). (2010). Nursing Scope and Standards of Practice (2nd ed.). Silver Spring, MD: Nursesbooks.org

ANA Standards ANA Standard 5-Implementation

The registered nurse implements the identified plan Partners with the person, family, significant others,

and caregivers as appropriate to implement the plan in a safe, realistic, and timely manner

Provides holistic care that addresses the needs of diverse populations across the lifespan

Utilizes community resources and systems to implement the plan

These competencies allow for the utilization of community resources and allows for holistic care of the homeless person

American Nurses Association (ANA). (2010). Nursing Scope and Standards of Practice (2nd ed.). Silver Spring, MD: Nursesbooks.org

ANA Standards ANA Standard 15-Resource Utilization

The registered nurse utilizes appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible Assists the healthcare consumer and family in

identifying and securing appropriate services to address needs across the healthcare continuum

Assesses individual healthcare consumer care needs and resources available to achieve desired outcomes

This standard allows the nurse to identify available resources that are financially responsible for the homeless person and the community while addressing the individual needs of each homeless person

American Nurses Association (ANA). (2010). Nursing Scope and Standards of Practice (2nd ed.). Silver Spring, MD: Nursesbooks.org

Conclusion Homelessness can have major

implications on health for individuals and communities

Statistics show that homelessness causes many physical, psychological, social and community health implications

A case management approach is a favorable method to improve health outcomes for the homeless person by providing resources and implementing complex health care plans

Conclusion A case management approach allows for

the use of Peplau’s Interpersonal Relationship Theory to be put into practice

A case management approach also allows for a homeless person to move up the pyramid of Maslow’s Hierarchy of Needs

References American Nurses Association (ANA). (2010). Nursing Scope and Standards of

Practice (2nd ed.). Silver Spring, MD: Nursesbooks.org Case Management Society of America (CMSA). (n.d.) What is a case manager? Retrieved from

http://cmsa.org/Home/CMSA/WhatisaCaseManager/tabid/224/Default/aspx de Vet, R., van Luitjelaar, J.A., Brilleslijper-Kater, S.N., Vanderplasschen, W., Beijersbergen, M.D., & Wilf,

J.R. (2013). Effectiveness of case management for homeless persons: A systematic review.

American

Journal of Public Health, 103(10), e13-e26. doi: 10.2105/AJPH.2013.301491 Gerber, L. (2013). Bringing home effective nursing care for the homeless. Nursing 2013, 43(3), 32,38.

doi: 10.1097/01.NURSE.0000426620.51507.0c

Hoonk, J. (2007). Case managing the homeless and the role of community health workers. Retrieved from

http://allnurses.com/general-nursing-discussion/case-managing-homeless-265503.html McCormack, R.P., Hoffman, L.F., Wall, S.P., & Goldfrank, L.R. (2013). Resource-limited collaborative pilot

intervention for chronically homeless, alcohol-dependent frequent emergency department users. American Journal of Public Health, 103, S221-S224. doi: 10.2105/AJPH.2013.301373

National Coalition for the Homeless. (2009). Health care and the homeless. Retrieved from http://www.nationalhomeless.org/factsheets/health.html

References National Health Care for the Homeless Council (NHCNC). (2011). Homelessness &

health: What’s the connection? Retrieved from http://www.nhchc.org/wp- content/uploads/2011/09/Hln_health_factsheet_Jan10.pdf Michigan’s Campaign to End Homelessness. (2012). Coming home: The campaign to

end homelessness synopsis. Retrieved from http://www.thecampaigntoendhomelessness.org/LinkClick.aspx?fileticket=chaQ9EMQ1e0

%3d&tabid=68 Nelson, R. (2012). Will health care reform increase access for the homeless? American Journal

of Nursing, 112(10), 19-20. doi: 10.1097/01.NAJ.0000421015.18545.52 Savage, C., & Lee, R.L. (2010). Caring for a homeless adult with a chronic disease. American

Nurse Today 5(3). Retrieved from http://www.americannursetoday.com/article.aspx?id=6376

Statistic Brain. (2013). Homelessness/Poverty stats. Retrieved from http://www.statisticbrain.com/homelessness-stats/ Zlotnick, C., Zerger, S., & Wolfe, P.B. (2013). Health care for the homeless: What we

have learned in the past 30 years and what’s next. American Journal of Public Health, 103, S199-S205. doi: 10.2105/AJPH.2013.301586