Quality of health care: the views of homeless youth.

Homeless youth are a medically underserved and vulnerable population in the United States. Based on recent research using a nationally representative sample of U.S. households, homelessness in adolescents ages 12–17 is more common than for adults (Ringwalt et al. 1998). In the United States and worldwide, communities commit resources and policies to address the problems and the needs of homeless youth, but comparatively few resources are placed on attempts to evaluate the impact of these policies and programs on the lives of homeless youth. Having ways to measure quality of care for homeless youth can help health programs establish performance monitoring in order to test and refine approaches to health care provision. Since homeless youth are more vulnerable and at-risk for negative health, improved quality of care for homeless youth has the potential for greater pay-off than for other groups of adolescents. Adolescents in general have unique barriers to access of appropriate health care and exhibit poor patterns of preventive primary health care (Wienick, Weiger, and Cohen 1998). Adolescents face barriers to health care including confusion over ability to legally consent for their own care, concerns over confidentiality of care, office hours that conflict with school, and discomfort with traditional adult-oriented health care settings (Klein et al. 1999). Of all age groups in this country, adolescents (including young adults) are the most likely to be uninsured or underinsured (English and Morreale 2003). Homeless people, including adults and adolescents, are characterized as having inadequate access to primary health care, and as seeking care at emergency departments (EDs) only after they are no longer able to ignore their health condition (Geber 1997; Institute of Medicine 1998). Being homeless creates health problems and makes health care more difficult to obtain, especially since basic needs such as food and shelter take priority over health care (Gelberg 1997; Zerger 2002). Homeless youth have greater problems with access to care than do homeless adults or nonhomeless adolescents, including a more profound lack of insurance/payment source, greater anxiety over confidentiality, more confusion over ability to consent for their own care, and less tolerance of lengthy waiting times and intake forms (Ensign and Gittelsohn 1998; Klein et al. 2000). An important and often overlooked factor in homeless youth access to care is that they do not have an adult to help them navigate the increasingly complex health care system. While the main structural factors of health care affecting access to care are known for homeless youth, the process and outcome factors are not well established. Measuring quality of health care has become a major focus of health services research in the United States. It is viewed as an essential step in improving the health of our population, in containing the rise in health care expenditures, and in increasing consumer confidence in the health care system (Department of Health and Human Services 1998). However, research on quality of care measures including outcomes for pediatric and adolescent health has lagged behind that for adults (McGlynn and Halfon 1998), as has that for underserved populations in general (Beltran 2000). A criticism of outcomes research is that it relies on research “experts” to define which outcomes are important and does not include consumer perceptions or definitions of desired outcomes (Ray 1999). Youth in particular are rarely considered to be experts about their own health needs and priorities, yet health programs that include youth throughout their design, implementation, and evaluation are more likely to be effective (World Health Organization 1997). There are no quality of care measures for adolescents that include youth-identified measures of quality, as well as no quality of care measures specific to homeless young people. To improve health care access and quality of health care services specific to homeless youth, valid performance measures need to be developed. The purpose of this study was to develop homeless-youth-identified process and outcome measures of quality of health care using qualitative methods.