Transcript Does a case management approach improve health status for

DOES A CASE MANAGEMENT
APPROACH IMPROVE HEALTH
OUTCOMES FOR HOMELESS
PEOPLE?
Staci Leyko, RN
Ferris State University NURS 450
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/
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???
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, S199S205. doi: 10.2105/AJPH.2013.301586
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/
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/
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
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%3
d&tabid=68
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
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
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
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
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
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
Maslow’s Hierarchy of Needs
Pyramid image of Maslow’s Hierarchy of Needs
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
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
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
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/wpcontent/uploads/2011/09/Hln_health_factsheet_Jan10.pdf
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 3/3/14only 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
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
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
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/wpcontent/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
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
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
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
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
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
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/casemanaging-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
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
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
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
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
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
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
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
References

National Health Care for the Homeless Council (NHCNC). (2011). Homelessness &
health: What’s the connection? Retrieved from http://www.nhchc.org/wpcontent/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