A scoping review examining patient experience and what matters to people experiencing homelessness when seeking healthcare.

BACKGROUND: Homelessness is associated with significant health disparities. Conventional health services often fail to address the unique needs and lived experience of homeless individuals and fail to include participatory design when planning health services. This scoping review aimed to examine areas of patient experience that are most frequently reported by people experiencing homelessness when seeking and receiving healthcare, and to identify existing surveys used to measure patient experience for this cohort. METHODS: A scoping review was undertaken reported according to the PRISMA-ScR 2020 Statement. Databases were searched on 1 December 2022: MEDLINE, EMBASE, APA PsychINFO and CINAHL. Included studies focused on people experiencing homelessness, healthcare services and patient experience, primary research, published in English from 2010. Qualitative papers and findings were extracted and synthesized against a modified framework based on the National Institute for Health and Care Excellence guidelines for care for people experiencing homelessness, the Institute of Medicine Framework and Lachman's multidimensional quality model. People with lived experience of homelessness were employed as part of the research team. RESULTS: Thirty-two studies were included. Of these, 22 were qualitative, seven quantitative and three mixed methods, from the United States of America (n = 17), United Kingdom (n = 5), Australia (n = 5) and Canada (n = 4). Health services ranged from primary healthcare to outpatient management, acute care, emergency care and hospital based healthcare. In qualitative papers, the domains of 'accessible and timely', 'person-centred', and values of 'dignity and respect' and 'kindness with compassion' were most prevalent. Among the three patient experience surveys identified, 'accessible and timely' and 'person-centred' were the most frequent domains. The least frequently highlighted domains and values were 'equitable' and 'holistic'. No questions addressed the 'safety' domain. CONCLUSIONS: The Primary Care Quality-Homeless questionnaire best reflected the priorities for healthcare provision that were highlighted in the qualitative studies of people experiencing homelessness. The most frequently cited domains and values that people experiencing homelessness expressed as important when seeking healthcare were reflected in each of the three survey tools to varying degrees. Findings suggest that the principles of 'Kindness and compassion' require further emphasis when seeking feedback on healthcare experiences and the domains of 'safety', 'equitable', and 'efficiency' are not adequately represented in existing patient experience surveys.

Examining the health and well-being profile of people experiencing primary homelessness: the social work perspective at a major metropolitan teaching hospital.

Objective The literature has established a significant increase in morbidity and mortality among people experiencing primary homelessness, along with a pattern of using acute hospitals in place of primary healthcare services. This study examined how health services can engage and support people experiencing homelessness. Methods Participants were prospectively identified by acute hospital social workers in the course of providing usual care. All participants identified as experiencing primarily homelessness immediately before acute inpatient hospital admission. This study used the Vulnerability Index - Service Priority Decision Assistance Tool (VI-SPDAT) and Personal Wellbeing Index - Adult (PWI-A) to evaluate vulnerability and well-being respectively. VI-SPDAT data was analysed using frequencies and proportions for categorical variables and mean ± s.d. for continuous variables. PWI-A data was analysed using one sample t-tests were used to compare the study sample against representative data from the general population. Study data identified factors present in the sample population which are likely to impact their engagement with health services. Results On the PWI-A, study participants (n = 14) scored significantly lower on all measures of well-being than a representative sample from the general population (P ≤ 0.05). The VI-SPDAT indicated that 79% of participants experienced trimorbid physical, mental and substance misuse issues, and had high rates of indicators of past or current trauma, such as abuse or assault leading to or occurring while homeless (71%) and being raised in foster care (50%). Conclusions In conclusion, a model of health care provision to a homeless population should incorporate a trauma-informed, multidisciplinary approach across the inpatient-community continuum. This is consistent with findings and recommendations of other studies and will lead to better health and well-being outcomes. The anticipated benefits of such an approach include a decrease in preventable health conditions and opportunities to address issues that are not the primary reason for seeking health care, including access to housing and treatment for substance misuse. What is known about the topic? It has been established in the literature that people who are experiencing primary homelessness are likely to experience morbidity and mortality at a far higher rate than domiciled people. It has also been established that an underutilisation of primary and preventative healthcare services by this group results in a higher rate of preventable health conditions than for domiciled people. What does this paper add? This paper adds information regarding personal well-being and indicators of vulnerability in a population of patients who were identified as experiencing primary homelessness during an acute hospital inpatient admission. Analysis of these results provides a picture of the types of health conditions experienced by the participants, as well as indicators of trauma and adverse life events. We propose a model of healthcare service delivery that this study indicates would decrease the rate of preventable health conditions in the homeless population. This model would also provide a way to engage people experiencing homelessness. This then provides an avenue by which issues other than the primary reason for seeking health care can be addressed with this group, such as housing and treatment for substance misuse. What are the implications for practitioners? This paper provides a proposed model of health care delivery based on evidence from the present study and other literature. The evidence suggests that the model proposed would more effectively engage people experiencing homelessness in addressing their healthcare needs and reducing unnecessary utilisation of acute hospital inpatient beds.