Nurses should be front and center in providing care and improving health outcomes for homeless populations, according to Jillian J. Weber, PhD, RN, CNL, Homeless Patient Aligned Care Team (HPACT) National Program Manager, Homeless Programs Office, Veterans Health Administration (VHA). Weber, who authored "A Systematic Review of Nurse-Led Interventions with Populations Experiencing Homelessness," published January/February 2019 in Public Health Nursing, said the science demonstrates nurse-led models of health care for the homeless improve outcomes. [caption id="attachment_103165" align="alignleft" width="245"]
Jillian J. Weber, RN[/caption] "Studies show that nurse-led interventions effectively engage patients experiencing homelessness in positive health seeking behaviors, such as smoking cessation and medication adherence. Nurses effectively help patients reduce risky behaviors, including risky sexual behaviors and marijuana use. And nurse-led work with homeless populations has been shown to improve patients' quality of life, overall," Weber said.
The Growing Necessity of Health Care for the Homeless
The U.S. Department of Housing and Urban Development (HUD) estimates homelessness in terms of a point-in-time (PIT) count. The most recent published numbers from just before the pandemic in January 2020, showed 580,466 people experienced homelessness in the United States on a single night in 2020, a 2.2% increase from 2019. The number of people who are homeless and living on the streets and other areas not suitable for living, compared to homeless people in shelters, was up 7%, according to HUD. "Based on what we know about the pandemic -- job loss, illness, eviction moratoriums expiring -- the number of people facing homelessness in 2021 is likely to be higher," Weber said. People experiencing homelessness generally need a holistic approach to care, according to Weber. That includes addressing patients' physical, mental, psychosocial and emotional needs. It involves thinking about the social determinants of health, including employment, hygiene, and barriers to access such as transportation, Weber continued. "The nurse-managed health clinics that are utilizing holistic approaches to care were shown to improve patient satisfaction, reduce health-related costs, and increase access to care," Weber said. "Putting RNs and advanced practice nurses in these clinics produces optimal health outcomes. They provide case management, advocacy, and the opportunities for patients to ask questions -- leading to that openness that builds trust." Building trust is pivotal to successfully caring for these patients, said Patricia Obulaney, DNP, APRN, ANP-C, Clinical Associate Professor, University of Houston College of Nursing.
"It's kind of like that saying, 'If you build it [trust], they will come,'" said Obulaney, who runs the new University of Houston College of Nursing Health Clinic that serves homeless patients in Houston. "In the homeless community, patients need to know that we are going to be kind and respectful of them as individuals. Once trust is established, then you build rapport with patients and word gets out."
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Patricia Obulaney, APRN[/caption] Obulaney, an RN, and a receptionist staff the new University of Houston College of Nursing Health Clinic. Because nurse practitioners do not have full practice authority in Texas, there is a collaborating physician for the primary care clinic. She said that since the clinic opened in September, she has seen patients with high blood pressure, as well as exhaustion. In a homeless population, the patient could be exhausted because they have anemia from poor nutrition, she said. "I've been seeing patients for scrapes. I saw a patient with a tibia fracture who had been dealing with it for three weeks and had not been able to get the care that he needs," said Obulaney, also a member of the American Association of Nurse Practitioners (AANP). "So, what we do is tap into the resources that are available in our community." Those resources include access to dental, eye, and other specialist care, mental health services, meals, and much more. Obulaney said she hopes to encourage more patients to practice preventive medicine.
"We had two patients this week say, 'I'm here because I want to get healthier,'" Obulaney said. "I love that I can provide some preventative care and a lot of teaching. That's what nurse practitioners are golden for, talking with patients about how their smoking is impacting their life, how their drinking is impacting their life, what street drugs can do to their body."
In the context of the pandemic, nurses and nurse-led programs are needed to increase vaccination in this vulnerable population, according to Weber. Nursing care would likely be valuable for a vaccine program's success given nurse case management and tracking is critical in homeless patients' adherence to completing a six-month hepatitis A and B vaccine series, according to a study published in in Nursing Research. A mobile nurse-led immunization service is another example of a successful approach for reaching vulnerable populations with influenza vaccines. The 2018 study by Australian researchers concluded the nurse-led model that takes vaccines to vulnerable populations is an important strategy for maximizing vaccine uptake.
Getting started
Weber said proving health care for the homeless populations is valuable and rewarding but remains challenging. "I think one of the biggest challenges for nurses is to have flexibility of practice -- being able to understand the prioritization of needs in this population," she said. "An individual might have elevated blood pressure, but that might not be the priority for that day. Prioritizing food, shelter, and safety might be the primary needs, as opposed to getting their blood pressure medication refilled." Nurses also have to keep an open mind about what these patients face that others might not, such as exposure to extreme cold during the winter or extreme heat in summertime.
"One of the most important roles of nurses providing care to people experiencing homelessness is being an advocate and giving a voice to this population -- advocating for a patient's needs based on the individual rather than a whole population," Weber said.
Nurses who build trust with patients might see them make healthier choices or progress from living on the streets to maintaining permanent housing. "But there are definite hardships," said Weber. "You can't save everyone." Nurses thinking about devoting their practices to providing health care for the homeless can start off by volunteering, Weber suggested. Homeless shelters, soup kitchens, and nursing organizations are often looking for volunteers ready to lend a hand, she said.
Take these courses related to this article:
Beyond Standardized Care for the Homeless and Mentally Ill
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Homelessness continues to be a significant problem in the United States. Serious mental health conditions and substance use disorders complicate care for this population. Emergency departments, walk-in clinics, and mental health centers are often areas where homeless individuals seek care or are brought in for care by law enforcement or community service workers. Healthcare professionals working in these settings must have knowledge of the complex issues associated with caring for the homeless and, more importantly, resources available to help this population.
Covid-19: Challenges Around Vaccinations
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This course provides objective analysis about challenges with the COVID19 vaccine and its acceptance by healthcare workers.
Medication Nonadherence
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Poor medication adherence has been called America's other drug problem. This issue attracts attention, resulting in major reports and literature such as the World Health Organization's Adherence to Long-Term Therapies. Roughly 50% of patients do not take medications as prescribed. Poor medication adherence can lead to unnecessary disease progression and complications. Nurses can favorably impact medication adherence across the healthcare continuum during hospitalization, following discharge, in clinics/offices, and in the community. A knowledge deficit exists in healthcare as to the causes of medication nonadherence. It is important to understand the causes of nonadherence and methods to help improve medication adherence.
