Implementing a health screening program for persons experiencing homelessness : a Canadian example

The resource center clinic implemented a health-screening program for the population of people experiencing homelessness or precarious housing situations. One of the program intentions was to align service with BCMH and MCFD goals of increased accessibility, increased screening and preventative health care services, and increased integration of primary care and mental health and substance use services. The clinic hours are limited and available Wednesday mornings from 0830 until noon. On average 7 new patients were seen each month. The patient population was predominantly male, the average age was 45.6, and 50% were homeless. There was a high prevalence of prehypertension and prediabetes. Eighty five percent of patients had a positive screen for depression and this was higher than expected. Polysubstance use was more common for the patients as compared to use of alcohol only. The number of patients with positive HCV screening was within the expected range. Seventy nine percent of patients seen in the clinic for screening smoke cigarettes. Patients with prediabetes and prehypertension require more frequent screening. Further assessment and intervention with regards to nicotine dependence is needed. For patients presenting with depression, the addition of group or online CBT could help improve outcomes. In order to improve the health outcomes for HCV positive patients it is important to develop links with clinics offering support and treatment for HCV. To improve the health of this population we need to increase the number of clinic hours and offer clinic time later in the day. Additionally, reducing barriers to screening such as offering non-fasting lab tests, using a one page tool that incorporates screening for depression, alcohol use and substance use, and having one key person completing the initial screening may increase consistency and patient participation. HOMELESS: HEALTH SCREENING 3 Homelessness and the associated health issues are a significant problem in British Columbia. Innovative ways to reach and support the health needs of the homeless population are required as traditional methods have been largely ineffective. Establishing care partnerships is challenging because of limited health care resources and the stigma surrounding this population. Improving health access and outcomes for persons experiencing homelessness will decrease the financial burden placed on provincial health authorities by reducing Emergency Department (ED) visits and avoiding inpatient admissions. An overarching goal of this project in addressing the specific health needs of those experiencing homelessness is offering low barrier healthcare through a clinic linked with a housing first program. This model is possible through a partnership between Progressive Housing Society (PHS) and the Fraser Health Authority (FHA). The purpose of this practice improvement project is the development of an appropriate and relevant health-screening program that meets both the needs of the population and the provincial mandate and goals. Through the screening program patients are linked to appropriate treatment and services with a goal of early intervention and care planning. Population Homelessness is a significant problem in Canada and there are at least 200,000 Canadians experiencing homelessness every year with an annual economic burden of seven billion dollars (Gaetz, Donaldson, Richter, & Gulliver, 2013). In British Columbia the largest homeless population is found in the metropolitan areas including Burnaby. Hundreds of Burnaby residents are affected by homelessness, as well as the associated health, social, and economic disparities. “Homelessness describes the situation of an individual or family without stable, permanent, appropriate housing, or the immediate prospect, means and ability of acquiring it” (The Canadian Homeless Research Network [CHRN], 2012). Furthermore, there is a range of housing HOMELESS: HEALTH SCREENING 4 circumstances including unsheltered absolute homelessness, sometimes referred to as sleeping ‘rough’, emergency shelters, provisional or temporary housing, and precarious housing with risk of homelessness (CHRN, 2012). The homeless lifestyle promotes illness and poor health and the transient nature of the experience of homelessness leads to disjointed health care (Wise & Phillips, 2013). Social determinants of health are linked to a person’s general living conditions and these factors exert a significant influence on health (Mikkonen & Raphael, 2010). There are several social determinants of health and those most closely aligned with homelessness are housing, unemployment, food insecurity, social exclusion, and access to health services. Basic physiological needs such as food and housing take priority over health concerns (Wise & Phillips, 2013). Poor housing quality leads to stress, poor coping, and adverse health outcomes and this positions housing as a basic requirement for health (Daiski, 2007; Mikkonen & Raphael, 2010). Epidemiology A person who is homeless has a higher mortality rate than the general population (Hwang, Wilkins, Tjepkema, O’Campo, & Dunn, 2009; Morrison, 2009). Common health issues for people experiencing homelessness include diabetes, hypertension, hepatitis C, mental illness, and addiction. Many of these conditions are either preventable or could be effectively managed with the provision of routine primary health care (Savage, Gillespie, & Lindsell, 2008; Schanzer, Dominquez, Shrout, & Caton, 2007; Weber, Thompson, Schmiege, Peifer, & Ferrell, 2013). Mental illness and substance use disorders are reported to be significant in the homeless population and 54% of people experiencing homelessness reported addiction issues and 35% reported having a mental illness (Regional Steering Committee on Homelessness, [RSCH], 2012). According to Savage et al., (2008) people experiencing homelessness rely on the hospital HOMELESS: HEALTH SCREENING 5 emergency department (ED) for their medical care needs because they do not have a primary care provider. According to the 2014 report from the British Columbia Ministry of Health (BCMH) people with severe mental health and/ or substance use disorders use a proportionally high percentage of expensive health care services such as Emergency Department (ED) and inpatient beds. Review of the Literature A review of the literature explored current information related to health issues, screening and treatment, and care access for people experiencing homelessness. The first search was done with CINAHL and MEDLINE using the terms ‘homeless’, ‘health’, ‘access’, with the limits of English language, peer reviewed, adults (age 19+), and the years 2001-2014. This search yielded 52 articles. Another search was done specifically for screening of the common conditions using the terms ‘screening’, ‘alcohol’, ‘diabetes’, depression’, hepatitis C’, and ‘hypertension’, with the limits of English language, peer reviewed, adults (age 19+), and the years 2001-2014 yielded 30 articles. Following the data analysis, a final search was completed using key terms ‘prediabetes’, prehypertension’, ‘smoking’, ‘homeless’, and ‘treatment’, with the same limits as above resulting in articles. A manual journal search and search of reference lists produced 18 articles. After eliminating duplicates and studies that did not meet inclusion criteria of adult, mental health and/or substance use, homeless, and health disparities, and screening, 36 articles were chosen for review. Three government websites, six professional organization websites, five practice guidelines, and one book were accessed for further information regarding policy, epidemiologic trends in the homeless population, current issues in practice, and clinical practice guidelines. HOMELESS: HEALTH SCREENING 6 There is one national program in the United States called Health Care for the Homeless (HCH). HCH has done extensive work to modify clinical practice guidelines specifically for the unique need of this population and these were reviewed. The themes emerging from this literature review are, the health status of people experiencing homelessness, barriers to health care access, and health screening. Provincial policy and clinical practice guidelines specifically for the homeless population are included. Health Status The relationship between poor health and homelessness is highly complex because the risk factors for homelessness are also risk factors for ill health (Frankish, Hwang, & Quantz, 2005). People experiencing homelessness tend to have a greater burden of health issues, require more intense treatment, and have higher rates of hospitalization as compared to the general population (BCMH, 2014; Daiski, 2007). Mortality rates of people experiencing homelessness are significantly greater than the general population (Cheung & Hwang, 2004). According to Frankish et al., (2005) men are between two and eight times more likely to die and homeless women are thirty-one times more likely to die than people who have stable housing. Common health conditions within this population include diabetes, hypertension, hepatitis C, mental health issues, and substance use disorders (Frankish et al, 2005; Hwang et al., 2010; Savage et al., 2008; Schanzer et al., 2007; Weber et al., 2013). The prevalence of diabetes in Canada is estimated at 7.6% and is about equal for the homeless population and the general population (Greiver et al., 2014; Jones et al., 2009). However, poor glycemic control has a prevalence of about 44% in the population of people experiencing homelessness as compared to 23% in the general population (Jones et al., 2009). Persons with diabetes have a significantly increased risk of cardiovascular disease estimated at 2-4 times more prevalent than those without HOMELESS: HEALTH SCREENING 7 diabetes (Canadian Diabetes Association [CDA], 2013). Additionally, there is a higher incidence of stroke and peripheral vascular disease and the