WellNest: A Medical Student-Run Housing Support Program.

PROBLEM: Being unhoused and facing housing insecurity contribute to poor health outcomes. Medical school curricula may include social determinants of health (SDOH) topics. However, experiential learning opportunities allow students to better contextualize how SDOH impact patients. The WellNest Housing Support Program (WellNest) was conceived and developed by Duke University medical students to learn from and support community members with a history of housing insecurity. APPROACH: Under the supervision of community organizations providing housing assistance services, WellNest was created in April 2020. Medical student-volunteers (MSVs) call clients, who are referred to WellNest by the community organizations, to plan move-ins. Local experts provide trainings on topics relevant to health care for individuals experiencing loss of housing. MSVs source and move furniture and clients' belongings into the new homes. Following move-in, MSVs are paired with clients to provide longitudinal tenancy support for at least one year. Student-volunteers contemplate their experiences and learning takeaways through debriefing sessions and an optional online survey. OUTCOMES: From fall 2021 to spring 2023, 83 student-volunteers from across the university participated in WellNest. Student-volunteers were generally medical students (37, 45%), and 16 MSVs served on the leadership team. WellNest facilitated 29 move-ins, and 26 clients requested to be paired with MSVs for longitudinal tenancy support. Following participation in WellNest, student-volunteers reported increased comfort, awareness, knowledge, and motivation related to caring for, discussing, and advocating for individuals experiencing housing insecurity. NEXT STEPS: As students from other programs are also interested in WellNest, there is potential for interprofessional education. Student-volunteers will be encouraged to participate in additional opportunities for reflection and advocacy activities. The impact of WellNest on clients will be explored through a questionnaire and narrative interviews. Long-term financial support was secured from community donations and partnering community organizations.

Opportunities for Nurses to Decrease the Stigma Associated with Housing Instability and Homelessness.

The number of people experiencing homelessness (PEH) in the United States has increased in the past 5 years. PEH have a higher disease burden and early mortality compared to people who are housed. Stigma adds to the burden of disease and disease management for PEH. In this article the authors review stigma, define housing and homelessness, describe the health and health care disparities PEH experience, and using the socio-ecological model as a framework, offer opportunities for nurses to intervene in efforts to decrease the stigma that PEH and housing instability encounter to improve health outcomes.

Protocol of a mixed method research design to study medical respite programs for persons experiencing homelessness.

Medical Respite Programs (MRPs) characterize a care model that has been developed to address the health care and social needs of persons experiencing homelessness by providing post-acute hospital care in a safe environment. Although this model has been shown to reduce hospitalizations, improve health outcomes and increase access to health services, prior studies of MRP programs and outcomes have been limited to individual sites and may not generalize to the population of individuals receiving MRP care. This study protocol describes a mixed method design to collect organizational, provider, and patient-level data from a sample of MRPs.

Cost-Effectiveness of a Homeless Care Transition Program: Durham Homeless Care Transitions.

BACKGROUND Transitional care and medical respite programs provide assistance to people experiencing homelessness as they move from acute care into community settings. These programs can address issues that may fall outside the reach of traditional medical care yet have a profound impact on the health of vulnerable populations. This article focuses on the cost-effectiveness of the Durham Homeless Care Transitions (DHCT) program.METHOD This intervention study of the DHCT program uses a comparison group of people experiencing homelessness who were referred but did not participate. Encounter-level data, aggregated by quarterly segments of charges and reimbursements, were abstracted for all persons referred. Descriptive statistics were computed and models of charges and reimbursements were created using ordinary least squares (OLS) regression to compare utilization for 12 months pre- and post-referral.RESULTS Patients referred to the DHCT program (N = 485) were primarily non-Hispanic Black (62.5%), male (68.4%), uninsured (35.5%), and had an average of 5.3 chronic conditions and an average age of 50.0 years (SD = 11.3). There was variability among charges and reimbursement based on health care visit type but a negative association between treatment and charges, indicating that being part of the DHCT program led to lower charges post-referral.LIMITATIONS The study is limited by lack of access to line-item details of charges, reimbursement, and payer mix.CONCLUSION There is evidence of benefit to patients from transitional care and medical respite programs that does not substantially increase the overall societal cost of care; however, health systems commonly require evidence of cost savings and benefit as a return on investment.

Program Outcomes and Health Care Utilization of People Experiencing Homelessness and Substance Use Disorder after Transitional Care Program Engagement.

People experiencing homelessness (PEH) have a high prevalence of mental illness and substance use disorder (SUD) and substantial acute and chronic disease burden. Transitional care and medical respite programs facilitate a safe transfer for PEH from the acute care to community setting. Many medical respite programs practice harm reduction strategies that can increase the opportunity for positive program outcomes for PEH with SUD. This transitional care and medical respite program evaluation explored program outcomes, health care utilization patterns, and comorbid conditions of persons with and without SUD. People experiencing homelessness with SUD had similar program outcomes and both groups had decreased acute care utilization after program engagement. A high prevalence of trimorbidity, which is associated with early mortality, was noted. Opportunities for harm reduction strategies to promote both social and clinical outcomes are offered.

Use of health care utilization as a metric of intervention success may perpetuate racial disparities: An outcome evaluation of a homeless transitional care program.

OBJECTIVE: This study explored race-based differences in disease burden, health care utilization, and mortality for Black and White persons experiencing homelessness (PEH) who were referred to a transitional care program, and health care utilization and program outcomes for program participants. DESIGN: This was a quantitative program evaluation. SAMPLE: Black and White PEH referred to a transitional care program (n = 450). We also analyzed data from the subgroup of program participants (N = 122). Of the 450 referrals, 122 participants enrolled in the program. MEASURES: We included chronic disease burden, mental illness, substance use, health care utilization, and mortality rates for all PEH referred. For program participants, we added 6-month pre/post health care utilization and program outcomes. All results were dichotomized by race. RESULTS: Black PEH who were referred to the program had higher rates of hypertension, diabetes, renal failure, and HIV and similar post-referral mortality rates compared to White PEH. Black and White PEH exhibited similar program outcomes; however, Black PEH revisited the emergency department (ED) less frequently than White PEH at 30 and 90 days after participating in the program. CONCLUSIONS: Health care utilization may be a misleading indicator of medical complexity and morbidity among Black PEH. Interventions that rely on health care utilization as an outcome measure may unintentionally contribute to racial disparities.

Changes in health and health care utilization following eviction from public housing.

OBJECTIVES: This study sought to (1) determine the number of persons evicted from the Durham Housing Authority (DHA) over a 5-year period, (2) explore changes in the number of persons with various medical diagnoses and health care utilization patterns before and after eviction, and (3) examine how many persons evicted from DHA became literally homeless. DESIGN: This was a pre/post cross-sectional quantitative study. SAMPLE: Heads of households evicted from DHA properties from January 1, 2013 through December 31, 2017 were included in the study. MEASUREMENTS: We matched people evicted by the DHA in a university health system electronic health record system to determine changes in diagnoses and health care utilization before and after eviction. We also matched the cohort in the homeless management information system to determine how many persons evicted became literally homeless. RESULTS: Findings indicate statistically significant increases in persons with medical diagnoses in five of ten categories, total hospital admissions, and emergency department visits after eviction. Of the 152 people included in the study, 34 (22%) became literally homeless. CONCLUSIONS: Health and health care utilization patterns were different before and after eviction. Implications for clinicians are explored.

Perceptions of Glove Use During Vaccination: A Cross-Sectional Study.

PURPOSE: To better understand clinic attendees' perceptions of nonsterile glove (NSG) use during vaccination and their concern for the environment. DESIGN: This was a cross-sectional, self-administered, in-person survey. METHODS: A nonrandom volunteer sample of vaccination clinic attendees (n = 789) completed a survey assessing their perception of NSG use during influenza vaccination administration and their concern for the environment. FINDINGS: Nearly all respondents equated NSG use with increased safety and professionalism. More than half of respondents reported feeling concerned about environmental waste associated with NSG use. CONCLUSIONS: NSG are not indicated for routine vaccination. Adherence to evidence-based practices on NSG use during vaccination can substantially reduce associated medical waste. Nurses can lead by example by only using NSG when indicated.

A Syringe Service Program Within a Federal System: Foundations for Implementation.

BACKGROUND: Drug use, specifically opioid use, is a public health crisis in the United States. Harm reduction programs, including syringe service programs, show efficacy in improving individual and public health outcomes. Healthcare provider perceptions are an important initial assessment when considering implementing a syringe service program. OBJECTIVE: The objective of this quality improvement project, completed in a Northeastern Veterans Affairs Medical Center (NEVAMC), was to lay the groundwork for implementation of a syringe service program. METHODS: This multiphase project included an initial needs assessment with stakeholders to determine the scope of substance use disorder within the facility and initiated the change process needed for syringe service program implementation. We administered an online survey, the Drug and Drug Problems Perceptions Questionnaire (DDPPQ), to better understand staff perspectives of and comfort in working with people who use drugs. Two educational modules were developed and conducted for staff to increase their knowledge, skills, and trauma-informed practices when working with people who use drugs. Standardized document templates for program implementation in federal systems were also developed. RESULTS: The needs assessment identified 266 patients who could benefit from expanded harm reduction services and a recognition that staff perception be assessed within the facility. The DDPPQ, completed by 153 staff members, indicated positive perceptions of people who use drugs and ability to counsel/treat people who use drugs. The median DDPPQ total score was 73, indicative of an overall positive perception. Sixty-eight staff members attended the initial education session, and 35 attended the second session designed specifically for mental health service line professionals. CONCLUSION: The findings indicate NEVAMC staff members have a high level of comfort working with people who use drugs. The staff educational programs were well received and have become a part of routine staff training at the NEVAMC. The standardized document templates are available for persons developing a syringe service program within a federal system.

Improving the Health of Public Housing Residents Through a Housing Authority and Nursing School Partnership.

The connection between health and housing is well-established. People who are precariously housed have worse health than those who have stable housing arrangements.- Persons moving into public housing have a higher illness burden than the general population, and public housing residents engage in less healthy behaviors, which contribute to public housing residents having poorer health than persons living in other housing situations. Public housing authorities and residents can benefit from authentic and constructive relationships with academic partners; academicians and students can benefit from engaging in partnerships with housing authorities and residents to better understand the connection between housing and health. This article describes the well-established relationship between the Duke University School of Nursing (DUSON) and the Durham Housing Authority (DHA), the evolution of that relationship, our collaborative work in improving the health of DHA residents while advancing nursing education and science, and lessons learned.

Increasing physical activity with African-American women using Facebook™ and Pedometers.

More than 80 percent of African American women struggle with overweight and obesity. We implemented a 5-week physical activity intervention using Facebook™ and pedometers with African American women. Twenty-seven African American women participated in a single-group pre/post design intervention to promote walking and physical activity. Participants were given access to a private Facebook™ group along with a free Omron Alvita pedometer. The five-week intervention challenged participants to increase weekly daily steps and the number of days they were physically active. At the end of the intervention, participants had significantly increased their weekly steps by 190% as compared to baseline (p = .005). Nearly, 80% of participants reported being active two or more days per week as compared to baseline (35.7%). Technologies such as social media and pedometers can assist in educating individuals and improving physical activity. These findings are relevant to public health nurses when implementing programs to increase physical activity for African American women.

Differences in Clinical Outcomes of Adults Referred to a Homeless Transitional Care Program Based on Multimorbid Health Profiles: A Latent Class Analysis.

Background: People experiencing homelessness face significant medical and psychiatric illness, yet few studies have characterized the effects of multimorbidity within this population. This study aimed to (a) delineate unique groups of individuals based on medical, psychiatric, and substance use disorder profiles, and (b) compare clinical outcomes across groups. Methods: We extracted administrative data from a health system electronic health record for adults referred to the Durham Homeless Care Transitions program from July 2016 to June 2020. We used latent class analysis to estimate classes in this cohort based on clinically important medical, psychiatric and substance use disorder diagnoses and compared health care utilization, overdose, and mortality at 12 months after referral. Results: We included 497 patients in the study and found 5 distinct groups: "low morbidity" (referent), "high comorbidity," "high tri-morbidity," "high alcohol use," and "high medical illness." All groups had greater number of admissions, longer mean duration of admissions, and more ED visits in the 12 months after referral compared to the "low morbidity" group. The "high medical illness" group had greater mortality 12 months after referral compared to the "low morbidity" group (OR, 2.53, 1.03-6.16; 95% CI, 1.03-6.16; p = 0.04). The "high comorbidity" group (OR, 5.23; 95% CI, 1.57-17.39; p < 0.007) and "high tri-morbidity" group (OR, 4.20; 95% CI, 1.26-14.01; p < 0.02) had greater 12-month drug overdose risk after referral compared to the referent group. Conclusions: These data suggest that distinct groups of people experiencing homelessness are affected differently by comorbidities, thus health care programs for this population should address their risk factors accordingly.

Identifying Patients Experiencing Homelessness in an Electronic Health Record and Assessing Qualification for Medical Respite: A Five-Year Retrospective Review.

Our team developed a transitional care and medical respite program for people experiencing homelessness and designed a retrospective chart review study to more fully understand the unique needs of this population. Using four independent techniques, we identified individuals (N=1,656) who were experiencing homelessness during at least one hospital encounter (emergency department and/or in-patient admission) in a teaching hospital in the Southeastern United States over a five-year period. Data were manually abstracted from a random sample of patients to determine which patient encounters would or would not have qualified for medical respite if it had been available at the time. This article reports the methods used to identify people experiencing homelessness in the electronic health record, the data abstraction process, the cohort description, and the primary reasons patients would not have qualified for the medical respite program.

Health care utilization following a homeless medical respite pilot program.

OBJECTIVE: The purpose of this study was to evaluate a homeless medical respite pilot program to determine if program participants had health care utilization pattern changes and improved connection to income, housing, and health care resources post program. DESIGN: This is a quantitative descriptive pre-/post-program evaluation. SAMPLE: A total of 29 patients experiencing homelessness and discharged from an acute care hospital in the southeastern United States were provided with housing and nursing case management. MEASUREMENTS: Demographics including age, sex, race, and ethnicity were collected. Connection to primary care, mental health, substance abuse services, income, insurance, and housing were assessed at program entry and completion. Health care utilization and charge and payment data were collected 1 year prior and 1 year post-respite stay. RESULTS: Participants demonstrated reduced hospital admissions (-36.7%) and when admitted, fewer inpatient days (-70.2%) and increased outpatient provider visits (+192.6%). Health care charges for the cohort decreased by 48.6% from the year prior to the program. Housing and income improved. CONCLUSIONS: The medical respite pilot program was successful in guiding patients to community resources for more appropriate health care at a demonstrated cost savings. Participants also derived benefits in the form of improved housing and income.

Collaborating with Public Housing Residents and Staff to Improve Health: A Mixed-Methods Analysis.

This study described the health behaviors and barriers and facilitators of those behaviors in elderly and/or disabled residents of public housing. A mixed-methods design was used. Residents (N = 88) completed a survey with validated measures of health behaviors. A sub-sample (N = 16) participated in three focus groups. Residents scored worse than population norms on the majority of behaviors measured. Qualitative results framed in an ecological model indicated the majority of facilitators and barriers to health behaviors were perceived as occurring at the intrapersonal and interpersonal levels. Interventions to promote health should consider the unique barriers and facilitators to health behaviors among residents.

Barriers to Care for Transgender People: A Conversation With Dana Hines, PhD, MSN, RN.

A public health nurse talks about her career trajectory, her entry into nursing research, and her research career in transgender health. Transgender people encounter many health and social disparities, yet medical and nursing professionals are often ill-prepared to care for this population of individuals. The nursing profession is well known for its contributions to population health and for developing nursing-led interventions to improve the health outcomes of marginalized populations. Hines urges nursing to take a more active stance in transgender health and is leading this effort by example.

Desired Destinations of Homeless Women: Realizing Aspirations Within the Context of Homelessness.

Despite recent decreases, homelessness remains a substantial problem in the United States. Homelessness is associated with poor health, and homeless women experience earlier mortality than their housed counterparts. Understanding the aspirations of homeless women may offer service providers avenues for intervention to increase well-being among this vulnerable population. This study, a secondary analysis of transcribed interviews (n = 20), provides insight into the aspirations of homeless women. Opportunities for service providers to intervene on these aspirations within the context of homelessness are offered.

Coalition Building for Health: A Community Garden Pilot Project with Apartment Dwelling Refugees.

Refugees often experience compromised health from both pre- and post-migration stressors. Coalition theory has helped guide the development of targeted programs to address the health care needs of vulnerable populations. Using the Community Coalition Action Theory as a framework, a coalition was formed to implement a community garden with apartment-dwelling refugees. Outcomes included successful coalition formation, a community garden, reported satisfaction from all gardeners with increased vegetable intake, access to culturally meaningful foods, and evidence of increased community engagement. The opportunity for community health nurses to convene a coalition to affect positive health for refugees is demonstrated.

Using research poetics "responsibly": applications for health promotion research.

Research poetics, a form of arts-based research methods, has been under-utilized in the field of health promotion. Poetic methods have most commonly been used as a form of re/presentation of the lived experience in qualitative research. For the community-engaged researcher, re/presenting findings through poetry offers unique opportunities for engaging the reader and reaching diverse communities. However, this approach also has implications as an analytic method and allows the analyst to have a more meaningful and personal engagement with participants' stories. Perhaps most importantly, this approach acknowledges and brings to the forefront the co-construction of qualitative findings and de-centers the authority of the researcher by preserving and promoting the participant's voice. Using examples from the authors' own research, this article describes opportunities for incorporating research poetics into health promotion research and argues for its applicability for community-engaged health promotion researchers.