BMC Health Services Research
Literature Review Topic
***Eliminating discharge delay in the low-income and homeless population in the emergency room**
Much effort should be devoted to this section as it is a key component of your work.
This should be a synthesis of the literature, not a catalog of studies or simply an analysis of the research you discover.BMC Health Services Research
**Perform a literature review using a minimum of seven (7) peer-reviewed articles and books, as well as non-research literature such as evidence-based guidelines, toolkits, standardized procedures, etc.
**Review of areas in relationship to medicine, nursing, public health, etc.
The review should be critical and synthesize rather than just being a catalog of studies.
Summarize the key findings of the research and its relevancy to your project that point out the scientific status of the phenomenon under question. Such a statement includes:
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What we know and how well we know it.
What we do not know.
Describe any gaps in knowledge that you found and the effects this may have on advanced practice nursing as it relates to your project topic.
Your integrative literature review should be 5–6 pages in length, not including the cover or reference pages.
You must reference a minimum of 7 scholarly articles published within the past 5–7 years.
***Use current APA 7TH EDITION format to style your paper and to cite your sources. Review the rubric for more information on how the assignment will be graded.
Delayed Discharge of the Poor and the Homeless from Hospital Emergency Departments: A Literature Review
Various studies and reports from both the United States and Europe have stated beyond doubt that homeless people are some of the most frequent visitors to hospital emergency departments. This is brought about by several factors. One of these is that the homeless population is poor and mostly lives below the poverty line. This makes them more affected negatively by the social determinants of health such as living conditions, access to quality healthcare, and healthcare coverage. The poor homeless are also more affected by certain disease conditions than the general population. These include frequent respiratory illnesses due to exposure to the elements at night, heart disease, and overdose from substance abuse. In this context, hospital emergency departments (EDs) need to have in place discharge plans for this unique population of patients. The topic for this paper is the elimination of delayed discharge of poor and homeless patients from hospital EDs. The paper is a literature review of seven articles whose theme is the delayed discharge of these patients from EDs across hospitals.BMC Health Services Research
Literature Review and Synthesis
Blackburn et al. (2017) have stated in their study that there is a close correlation between being homeless and having multiple morbidity. They also opine that the homeless have a very low uptake of preventive public health measures due to their nomadic nature. Their research shows that a homeless person is more likely to get poor discharge preparation and arrangement from hospitals. This assertion by these researchers may be true but he underlying reasons may be more than just the fact that the patient is homeless or poor. This could be a systemic and subconcious tendency to discriminate perpetuated by deep-seated societal biases. They used a methodology of population-based cohorts by observing the outcomes of discharge of three different groups of homeless and poor patients treated by different clinicians and discharged under different circumstances. They found that the poor discharge preparations and plans for homeless patients actually caused even more hospitalization costs as they resulted in preventable readmissions.
The observation that persons who are homeless are frequent visitors to the ED is supported by Buccieri et al. (2018). Their article discusses this topic within the context of Canada. Their study was an online survey of a sample of 660 respondents. The findings of these researchers merge with those of Blackburn et al. (2017) in that there is also no proper discharge planning in Canada for homeless patients. This study revealed that homeless agencies lack a framework of coordination with hospitals that could enable discharge to shelters. What this means is that these homeless patients are discharged back to the streets where conditions for the sick are deplorable. It is clear from this reality that the homeless person who is discharged into the streets will have a very high likelihood of falling sick again within a short time and getting readmitted again. Contributing factors to this include difficulties with medication compliance (since there is no proper place to store them for homeless person), exposure to hostile environmental conditions, and re-infection from fellow homeless people.
“Tri-morbibity”
Drawing from what has been mentioned above in the introduction; Cornes et al. (2018) opine that people who have been homeless for a long time tend to suffer from what they term as “tri-morbidity”. This is the state of being afflicted by three conditions namely physical illness, mental illness, and substance abuse. For these reasons alone, the homeless person is prone to visiting hospital EDs more frequently that the average normal person living under a roof. The study looked at ED visits by homeless persons in the context of the United Kingdom. They also acknowledge – just as Blackburn et al. (2017) and Buccieri et al. (2018) – that homeless people often experience difficulties when it comes to getting discharged from the hospital. In fact, they also acknowledge that it is these delays that normally eventually lead to unwanted and preventable readmissions. Readmissions in any healthcare context are normally a quality improvement (QI) red flag. Cornes et al. (2018) raise the concern of the lack of a proper framework for satisfying the needs of homeless persons discharged from hospitals in terms of transitional care. Getting a concrete solution to these issues may help in the reduction of discharge delays for homeless and poor patients.BMC Health Services Research
The close association between homelessness and a high rate of morbidity and mortality is also observed by Feigal et al. (2014). They not only aver that homelessness as a situation also makes one be hospitalised more frequently, but also that the homeless stay longer in hospitals and incur even higher hospitalization costs. In part, all these unfavorable outcomes result from the delay in discharging homeless patients. For many of these problems to be sorted out, therefore; the delay in discharging hospitalized homeless patients must be done away with. This calls for a multi-sectoral, multi-pronged, and multiple stakeholder approach. The researchers in this case sought to determine the reasons that cause discharge delays for homeless patients (not medical in nature), and any correlation to the status of the patient as a homeless person. They documented the length of discharge delay for every homeless patient as well as the nonmedical reason(s) for the delay. What they found was astounding. Up to 43% of those patients who experienced discharge delays were identified as being homeless. Also, the homeless without mental illness had discharge delays that were 60% longer compared to housed patients without mental illness. The homeless in this study turned out as more likely male and without medical insurance (Feigal et al. (2014). Again, this is another study that shows the need for eliminating discharge delays from hospitals. Low-Quality Discharge Care
The hypothesis that homeless persons are disproportionately affected by low-quality discharge care is also confirmed by Greysen et al. (2013). However, they go further to suggest that there are few to no efforts aimed at correcting this state of affairs. This is with regard to evidence-based patient-centered empirical data that may be used to direct quality improvement or QI incentives. Greysen et al. (2013) used both qualitative and quantitative data to try and establish a correlation between staff confirmation of homelessness status and the quality of discharge care offered. This research serves as a confirmation of the hypothesis presented earlier in this paper that the state of homelessness alone is not responsible for discharge delays. Rather, it is attributable to deep ingrained societal biases and discriminatory tendencies that are subconcious. Indeed, Greysen et al. (2013) found that homeless patients experienced stigmatization from the healthcare staff after disclosing the housing status to them. From the findings, elimination of discharge delays (improvement of discharge care) can be achieved by disabusing the healthcare staff of their prejudices and bigotry.
The article by Hochron & Brown (2013) on the discharge practices for homeless patients just cements what this literature review has now reliably established. The discharge of homeless patients after considerable delays is responsible for preventable re-hospitalizations, increased hospitalization costs, and generally poor patient outcomes. The proposed solution in this article by Hochron & Brown (2013) is collaboration between the healthcare fraternity and shelter providers. The aim of this is to assist the homeless patients discharged from the hospital with some form of shelter so that they may recuperate under somewhat favorable conditions. By doing this, the quicker discharge of these homeless patients will be possible. This is because the hospital staff will be aware that the patient has a place where they are going to recuperate. The fact that homeless people are more likely to visit hospital EDs more frequently is reiterated by Ku et al. (2014). They state that this definitely leads to higher hospitalization costs that they often cannot afford.
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A Summary of Findings and Gaps in Knowledge
From the findings of the above seven sources, we now know that homeless persons visit hospital EDs more frequently than their housed counterparts. We also know that they suffer stigma from the healthcare staff in the event that they reveal their housing status. Lastly, we know that the delay in discharge for homeless patients results in increased hospitalization costs and poor patient outcomes. The gap in knowledge or what we do not know in this case is how the stigma suffered by the homeless at the hands of hospital healthcare staff contributes to the burden of mental illness borne by the homeless. The effect that this may have on nursing practice is that psychiatric-mental health nurse practitioners or PMHNPs need to come up with an outreach program to offer counseling and psychotherapy to this population. BMC Health Services Research
References
Blackburn, R.M., Hayward, A., Cornes, M., McKee, M., Lewer, D., Whiteford, M., Menezes, D., Luchenski, S., Story, A., Denaxas, S., Tinelli, M., Wurie, F.B., Byng, R., Clark, M.C., Fuller, J., Gabbay, M., Hewett, N., Kilmister, A., Manthorpe, J., … & Aldridge, R.W. (2017). Outcomes of specialist discharge coordination and intermediate care schemes for patients who are homeless: Analysis protocol for a population-based historical cohort. BMJ Open, 7(12), e019282. https://doi.org/10.1136/bmjopen-2017-019282
Buccieri, K., Oudshoorn, A., Frederick, T., Schiff, R., Abramovich, A., Gaetz, S. & Forchuk, C. (2018), Hospital discharge planning for Canadians experiencing homelessness. Housing, Care and Support, 22(1), 4-14. https://doi.org/10.1108/HCS-07-2018-0015
Cornes, M., Whiteford, M., Manthorpe, J., Neale, J., Byng, R., Hewett, N., Clark, M., Kilmister, A., Fuller, J., Aldridge, R., & Tinelli, M. (2018). Improving hospital discharge arrangements for people who are homeless: A realist synthesis of the intermediate care literature. Health and Social Care in the Community, 26(3), e345-e359. https://doi.org/10.1111/hsc.12474
Feigal, J., Park, B., Bramante, C., Nordgaard, C., Menk, J., & Song, J. (2014). Homelessness and discharge delays from an urban safety net hospital. Public Health, 128(11), 1033-1035. https://doi.org/10.1016/j.puhe.2014.06.001
Greysen, S.R., Allen, R., Rosenthal, M.S., Lucas, G.I., & Wang, E.A. (2013). Improving the quality of discharge care for the homeless: A patient-centered approach. Journal of Health Care for the Poor and Underserved, 24(2), 444-455. http://dx.doi.org/10.1353/hpu.2013.0070
Hochron, J.L., & Brown, E.M. (2013). Ensuring appropriate discharge practices for hospitalized homeless patients. World Medical & Health Policy, 5(2), 175–181. https://doi.org/10.1002/wmh3.37
Ku, B.S., Fields, J.M., Santana, A., Wasserman, D., Borman, L., & Scott, K.C. (2014). The urban homeless: Super-users of the emergency department. Population Health Management, 17(6). https://doi.org/10.1089/pop.2013.0118
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