Does a case management approach improve health OUTCOMES for homeless people?

1. Does a case management approach improve health OUTCOMES for homeless people? Staci Leyko, RN Ferris State University NURS 450

2. 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/

3. 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???

4. 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 economy 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

5. 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/

6. 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/

7. 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

8. 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 disabilities 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Maslow’s Hierarchy of Needs Pyramid image of Maslow’s Hierarchy of Needs

16. 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

17. 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 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

18. 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

19. 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.0000426620.51507.0c National 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

20. 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 nation 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

21. 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

22. 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

23. 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 shelter National 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 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

24. 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.0000426620.51507.0c National Coalition for the Homeless. (2009). Health care and the homeless. Retrieved from http://www.nationalhomeless.org/factsheets/health.html

25. 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 system 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

26. 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

27. 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

28. 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

29. 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.html 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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