Strategic Plan for Homeless Patients' Congestive Heart Failure

Executive Summary

Homelessness is a significant problem affecting a notable portion of the U.S. population. There are approximately 2.3 million individuals currently living without stable housing (Koh & O'Connell, 2016). Various factors significantly contribute to homelessness, including poverty, child abuse and neglect, substance abuse and mental illness, and lack of employment (Fazel, Geddes, & Kushel, 2014). Homelessness is closely related to increased risks for chronic diseases. One specific concern is an increased risk of cardiovascular diseases, including congestive heart failure. Such risks result in increased healthcare utilization, which can be costly for healthcare facilities and society in general.

Several factors act as barriers to health care among the homeless population, including those diagnosed with congestive heart failure (CHF). These individuals may struggle with CHF due to lack of financial resources, social isolation, an erratic and transient lifestyle, lack of health insurance, the lack of a primary care provider, selling or losing medications, or the inability to follow medication directions due to lack of food or cognitive deficits associated with mental illnesses (Whitney & Glazier, 2004).

There is the need for an effective intervention program that will improve the quality of CHF care for the homeless. An appropriate program could assist in ensuring that the medical condition of homeless individuals with CHF is effectively managed. Adherence to medical regimens could offer an effective strategy for addressing the challenges facing the homeless population. Telephone technology will be used as the intervention tool for medication adherence. The technology is expected to improve medication adherence and reduce readmission rate to the ED.

Large numbers of homeless persons are found in large U.S. cities, such as Dallas. The homeless are a diverse community, with 43% of the residents speaking a language other than English. Nearly 28% of Dallas residents do not have health insurance, making access to health care a significant challenge. Additionally, 23% of Dallas residents live at or below the poverty line (Fazel et al., 2014). It is estimated that over 10,000 individuals in the city experience homelessness at some point during the year. The majority of the homeless in Dallas experience challenges in managing chronic diseases such as CHF due to limited healthcare access.

The plan will involve improving medication adherence through the use of cellphones with free service to the discharged patients. The hospital’s ED will create s multidisciplinary team consisting of physicians, nurses, social workers, pharmacists, nutritionists and psychologists. The intervention program will help in improving medication adherence and reducing ED readmissions among the homeless patients with CHF.

Background Information 

Homelessness has emerged as a significant socioeconomic problem in the United States. A considerable proportion of the United States' population is homeless. It is estimated that homeless individuals in the country are well over half a million on any given day. Some of the major risk factors for homelessness include poverty, interactions with the criminal justice system, adverse childhood experiences such as abuse and neglect, and metal health issues. It is important to realize that homelessness may adversely affect the quality of life of the individuals, increasing the risk of mortality. It is estimated that the average lifespan of homeless individuals ranges from 45-50 years. Moreover, mortality rates in the homeless population are four-fold higher than in the general population. This could be contributed in part to the increased risk for chronic diseases such as CHF (Hwang et al., 2013). Homeless populations live in poverty, and they lack access to good nutrition and quality healthcare. Therefore, the homeless population in the United States is at a higher risk of contracting a serious illness, which may significantly increase its mortality rates.

Homeless people utilize healthcare resources at higher rates compared to the housed population. Over one-third of the homeless population in the United States is hospitalized every year (Lin et al., 2015). This figure is high compared to that of the general U.S. population. Generally, homeless individuals are the heaviest users of ED services. For instance, inpatient admissions of homeless individuals in most urban areas account for up to 28% of total inpatient admissions (Hwang et al., 2013). One of the most significant challenges facing homeless individuals with regards to access to care is the lack of health insurance. Lack of health insurance coverage makes hospital admissions costly for the healthcare organizations.

CHF is a significant cause of hospitalization, heavy ED use, and high mortality rates among the U.S. homeless population. Homeless individuals are more likely to die from cardiovascular disease than those in the general population. For instance, men between the ages of 45 and 64 years are 50% more likely to die from cardiovascular diseases than men in the general population (Lee et al., 2005). Additionally, heart diseases are the leading cause of death among homeless men who are 64 years and above. Poor nutrition, inadequate diagnosis and treatment of hypertension, and drug and alcohol abuse are some of the factors that have contributed to the increased risk of cardiovascular disease (Lee et al., 2005).

People who lack housing face significant challenges regarding healthcare. Homeless populations find it very hard to adhere to medical regimens. This is because most of them are elderly, use alcohol, or lack primary care providers (Hunter et al., 2015). Moreover, other factors impede access to medication such as social isolation, lack of financial resources, and lack of health insurance. Some of the hospitals may not be willing to admit homeless individuals due to the high costs associated with such admissions. The erratic lifestyles of homeless individuals are a significant barrier to filling and taking medication. Some homeless patients may lose their medication or sell them for food, transportation, or financing illegal drug use (Hunter et al., 2015). Lack of access to a physician who can prescribe medication has remained a major factor contributing medication non-adherence among homeless populations in the United States (Hunter et al., 2015).

Poor interactions between homeless individuals and healthcare providers may serve as a barrier to seeking healthcare. Mostly the interaction between the healthcare providers and homeless individuals is characterized by perceived or real discrimination, as well as bias. Consequently, homeless persons in need of medical care may not report to healthcare facilities for treatment (Jones et al., 2009). This may result in increased rates of mortality among the homeless.

The lack of medication adherence is a significant problem related to the management of CHF among the members of the homeless population. Homeless populations often have a difficulty accessing medication due to lack of money (Hunter et al., 2015; Joseph, 2018). Access to medical care provider and transportation to pharmacies are also some of the barriers to effective medical care among homeless individuals. Another significant problem relating to medication adherence is the likelihood for homeless individuals to sell their medicines to buy food. This is because they consider food more important than adhering to medical regimens (Hunter et al., 2015).

It is important to realize that homeless populations lack health insurance. This lack of health insurance is a significant barrier to primary care physician. The erratic lifestyles of the homeless persons make it difficult for them to stick to a single primary care physician. As a result, the providers are unable to keep track of the medical records and know what medications were prescribed or what laboratory diagnostic was completed in the past. As such, the health outcomes of such individuals may not be positives given their inconsistencies in adhering to medication regimens (Holland et al., 2014). Some of the homeless individuals may be compelled to use EDs for non-emergency purposes due to lack of money.

Various lifestyle factors make it difficult for homeless persons to effectively manage CHF. Such factors include food insufficiency, and drug abuse. Financial constraints compel homeless persons with CHF to seek lower quality food from fast food restaurants. Such foods are often high in cholesterol, exacerbating their heart conditions (Jones et al., 2009; Stafford & Wood, 2017). Drug abuse is another major barrier to proper management of heart diseases, particularly congestive heart failure. Drugs make homeless individuals to forget their medication schedules. In some instances, homeless people may sell the prescribed drugs to get money for food. This adversely undermines the healthcare efforts made by primary care physicians. Therefore, an effective health intervention program is needed to initiate a behavior change among the members of the homeless population in order to improve their health outcomes

Based on the above challenges faced by the homeless population, particularly those suffering from CHF, there is a need for an effective intervention program that will help in improving the quality of care provided. An effective intervention program could help in ensuring that homeless individuals suffering from CHF recover fully within a short time. Strict adherence to proper diet and medical regimens could offer an effective strategy for improving outcomes.

U.S. cities, such as Dallas, have a significant number of homeless persons. Nearly 28% of the residents in Dallas do not have health insurance, making access to health care a significant challenge, and 43% of residents speak a language other than English. Additionally, 23% of the residents in the city live at or below the poverty line (Fazel et al., 2014). Most of the homeless residents in Dallas experience challenges in managing chronic diseases such as CHF due to limited healthcare access. Such individuals experience challenges including the inability to properly store medications, as well as a lack of emphasis on health maintenance and prevention.

Program Overview 

Description of the Project 

The intervention program is intended to help in reducing the number of ED visits and improve medication adherence among homeless patients with CHF. The plan will involve improving medication adherence through the use of cellphones with free service to the discharged patients. The hospital’s ED will create s multidisciplinary team consisting of physicians, nurses, social workers, pharmacists, nutritionists and psychologists. The multidisciplinary team will undergo a cultural sensitivity training in order to reduce the potential for perceived or real discrimination due to homelessness or mental illness. The intervention program will help in improving medication adherence and reducing ED readmissions among the homeless patients with CHF.

The intervention program will adopt a team-based case management approach. A multidisciplinary team will be created by the hospital’s ED to address the comprehensive needs of the homeless diagnosed with CHF. The team will include physicians, nurse practitioners, nurses, pharmacists, social workers, nutritionists, and psychologists who will be paid by the hospital. The team will develop a plan of care for the patients based on the underlying etiology of the heart failure. The etiology underlying the heart failure could be secondary lung disease, alcohol use, or drug abuse. Additionally, the team will seek to identify the unique needs of the homeless patients and address any barriers that may impede adherence to the proposed health management plan.

The multidisciplinary team will set collaborative goals with the homeless patients diagnosed with CHF. The collaborative goals will be informed by the underlying etiology of heart failure. The team will use the simplest and most appropriate medical regimen for the treatment of the clients. This is because homeless clients experience significant challenges in terms of adhering to the medical regimens (Hugtenburg et al., 2013). The patients will be provided with prefilled medication boxes that will help to ensure that patients adhere to the medication given. Bus tokens and food coupons will be given to the patients as an incentive for promoting hospital attendance for follow up care and proper nutrition.

The intervention program will also involve follow up care by social workers paid by the hospital. Follow up care will include case management by social workers and nurses. Cell phones will be given to patients on discharge. The hospital will pay for free service for the cellphone. The phones will include free, unlimited service for 2 months. An automated telephone system will contact each patient every day for 45 days and administer a three-question survey relating to the patient’s medication adherence, nutrition, and challenges faced. The clients will respond by pressing a designated number. Additionally, the cell phones will notify the clients to take medication at appropriate times of the day (McInnes et al., 2014). The intervention program will enlist the support of three shelters: Austin Street Center, Dallas Life, and Union Gospel Mission. The three facilities will help in ensuring that the patients undergo treatment under a less challenging environment. This will ensure that treatment provided to the homeless patients diagnosed with CHF becomes effective.

Population 

The target population for the intervention program is homeless individuals in the city of Dallas, Texas. The city of Dallas is home to approximately 1.3 million residents. According to the Texas Department of State Health Services (2016), the number of deaths resulting from heart disease in Dallas metropolitan area has been increasing over the years. The average number of deaths per years stands at approximately 9,000. This is a large number compared to the entire population. As such, heart diseases are a major cause of deaths in Dallas. Healthy lifestyle behavior are challenging in Dallas, particularly for the homeless population. One of the most significant barriers to healthy lifestyle among the homeless in Dallas is the lack of access to nutritious food. Although there are shelters in the city that offer temporary shelter and meals, they do not meet the needs of the ever-increasing homeless population. In some instances, the shelters have to close their doors to the homeless, exposing them to high-risk behaviors such as substance abuse, violence, and bad weather (Hugtenburg et al., 2014). Such behaviors may significantly compromise their health. Most of the homeless who are admitted to the ED are overweight and obese. Such observations point out to the need to promote healthy eating among the homeless. Poor nutrition contributes to the increasing number of heart diseases among the homeless people.

Treatment of CHF among homeless and subsequent presentation to the EDs due to barriers associated with self-managing their health condition is an important health issue. This is very important because members of the homeless population are at an increased risk for chronic cardiovascular conditions, including CHF. Research has shown that homeless men are 50 percent more likely to die from cardiovascular disease than their housed counterparts (Joseph, 2018; Lee et al., 2005). Additionally, heart disease is the leading cause of death among older men in the homeless population. The factors that have been identified to contribute to the increased risk of cardiovascular disease among the members in the homeless population include poverty, smoking, high prevalence of inadequately managed conditions, and unhealthy diet. Socioeconomic deprivation has been closely associated with admission and readmission to emergency departments for CHF.

Setting 

The setting proposed for the implementation of the intervention program is Parkland Hospital ED. The program will help to address the health issue relating to the need for quality improvement efforts in the treatment of CHF among homeless individuals in the city of Dallas. The quality improvement program will help to improve the coordination of care for homeless individuals diagnosed with CHF . Given the need for a health intervention program for homeless people with CHF in the city of Dallas, Parklands Hospital will provide a strategic location for assisting the patients. The homeless population in Dallas, particularly those with CHF, experience significant problems including lack of access to primary care, lack of affordable, nutritious food and lack of stable housing.

The setting also has several shelters in its vicinity, which can provide shelter for the patients while undergoing treatment. Providing shelter to the homeless who are under medication enhances the effectiveness of care provided. This is because availability of housing enhances adherence to medication regimens. The hospital will approach three of the shelters to offer support by housing the patients who are diagnosed with CHF. The program will address two key issues relating to the management of CHF: lack of adherence to medication and ED readmissions.

The hospital will be able to serve the needs of the increasing homeless population in Dallas by providing specialized care for CHF. There are services and resources that will facilitate the success of the intervention program around Parkland Hospital. The various shelters neighboring the hospital will provide support services for the program. For instance, the patients will need housing to ensure that they adhere to the prescribed medical regimen. Availability of shelter will eliminate the transiency of the patients hence increasing the likelihood of successful recovery. After the patients receive the medication, they will be referred to the shelters where they can get temporary housing. During the period of medication, the patients need to get nutritious food and a friendly environment promotes adherence to the medication regimen. Additionally, there are other resources relevant for homeless individuals with CHF, such as the “city square” and “our calling” for the homeless (D. Perkins, personal communication, February 16 th , 2018). There are also parks that can help the homeless to carry out physical exercise. Dallas also has an extensive transport system that will facilitate the movement of the homeless population, to and from the heath care facilities.

Importance of the Program 

The program is of particular importance to the city of Dallas. A significant proportion of the Dallas residents are homeless. The homeless population faces significant challenges ranging from lack of financial resources, lack of health insurance to poor nutrition (Stafford & Wood, 2017). These factors increase their risk of cardiovascular diseases, particularly CHF. It is important to realize that heart diseases account for a significant number of deaths in Dallas. Therefore, there is need for a health intervention program that will help in improving the quality of care for homeless individuals with CHF. The program will help in improving the health outcomes of the homeless individuals with CHF. Additionally, the program will help in promoting a positive behavior change in the homeless population. The program will employ several best practices and guidelines in the treatment of patients who present with CHF. As such, the program will benefit the homeless in Dallas, particularly those with CHF.

The program will be beneficial to the hospital as well as the homeless population. The hospital will benefit from satisfaction levels of the clients. When clients are satisfied, the hospital’s services will be rated highly in the industry hence elevating the reputation of the hospital involved. The homeless population in Dallas will benefit from the program because they will access quality and effective treatment for CHF. Therefore, the deaths resulting from CHF will reduce. Additionally, the quality of life will be improved for those who have CHF. Hospital readmissions will also be reduced significantly for those suffering from heart diseases. This will significantly reduce healthcare costs for the homeless.

The problem will be implemented in Parklands Hospital. The intervention program will begin at the emergency department. The guide will give detailed dietary recommendations that will assist the patients to maintain healthy lifestyles (Liangchawengwong et al., 2013). The intervention program will adopt a team-based case management approach. A multidisciplinary team will be created to address the comprehensive needs of the homeless individuals diagnosed with CHF. As such, the team will include physicians, nurse practitioners, nurses, pharmacists, social workers, nutritionists, and psychologists. The team will develop a plan of care for the patients based on the underlying etiology of the heart failure. The etiology underlying the heart failure could be secondary lung disease, alcohol use or drug abuse. Additionally, the team will seek to identify the unique needs of the homeless patients and address any barriers that may impede adherence to the proposed health management plan. The multidisciplinary team will set collaborative goals with the homeless patients diagnosed with CHF. The collaborative goals will be informed by the underlying etiology of heart failure. The team will also use the simplest and most appropriate medical regimen for the treatment of the clients.

Similar Evidence-Based Intervention Implemented Elsewhere with Successful Outcomes 

A similar evidence-based study was conducted at a large Veterans’ hospital located in the Southeastern United States. The study established that a set of care coordination strategies. The study employed a team-based case management approach involving a cardiologist, registered nurses, health services researchers, and research assistants (Shaw et al., 2014). The research participants were patients admitted to any acute care unit, being treated for heart failure. The study involved follow up phone call to assess self-management of the disease since hospital discharge.

The Chronic Care Model was used as the framework for the test of organizational change in the study. The model posits that there are several evidenced based interventions to improve care in terms of decision support, information systems, and delivery system design. The emphasis of the intervention was on providing patients with self-management support for their heart conditions. The model demonstrated that productive interactions with an informed and activated patient and a proactive practice team lead to improved patient outcomes.

Strategic Plan 

The strategy for successful implementation of the intervention program in the hospital will involve a coordinated partnership between the hospital and three shelters in Dallas. The intervention program will enlist the support of three shelters: Austin Street Center, Dallas Life, and Union Gospel Mission. The intervention will adopt a team-based case management approach, involving physicians, nurse practitioners, nurses, pharmacists, social workers, nutritionists, and psychologists. The target population for the program is the members of the Dallas homeless population, particularly those with congestive heart disease. Cell phones will be used to monitor the patients’ medication adherence.

Expected Outcomes 

The program is expected to have positive impacts on the well-being of the homeless individuals with congestive heart failure. The expected outcomes include;

Improved quality of life among the members of the homeless population with CHF. 

60% reduction in the number of emergency department admissions. 

Adoption of positive lifestyles such as eating nutritious food and performance of physical exercises. 

Increased cases of congestive heart failure among members of the homeless population in the city of Dallas 

Inputs 

Personal 

Physicians 

Nurse practitioners 

Nurses 

Pharmacists 

Social workers 

Nutritionists 

Psychologists 

Tools 

Cultural sensitivity training 

Cellphones 

Pharmaceuticals 

Outputs 

Improved adherence to medication regimen 

Regular attendance to appointments 

Reduced perceived and real discrimination 

-Desired lifestyle change among patients 

- 80% reduction in readmissions 

Outcomes 

Improved quality of life among the members of the homeless population with CHF. 

60% reduction in the number of emergency department admissions 

Reduction in deaths from CHF among the target population 

Projected Timeline 

Activity	Month 1	Month 2	Month 3
Cultural sensitivity training
Approaching local shelters
Identifying project team members
Conducting telephone surveys
Monitoring and evaluation

Theoretical Model for Behavior Change 

The theoretical model selected for the analysis is the Health Belief Model. The Health Belief Model was developed primarily to predict why individuals fail to participate in health-promoting behaviors. This model encompasses five constructs that include the perceived susceptibility to a particular health issue, the perceived severity of the issue, perceived benefits and risks of taking action to address the health issue, and the cues that spur action or behavior change (Baghianimoghadam et al., 2013). The model highlights the role of self-efficacy in influencing one’s propensity to engage in the health-related behavior. Additional mediating factors, which may influence these five constructs, include demographic variables such as socioeconomic status and age, coping skills, self-efficacy, and motivation (Holland et al., 2014). The model is based on the notion that self-efficacy influences behavior change. In addition, the model allows the individual to consider the risks and benefits of the proposed behavior change. In the Health Belief Model, the perceived risk, and benefits of taking action play a role in the performance of the behavior. The utilized this model to establish the effectiveness of a health intervention program in assisting homeless individuals with CHF. A similar evidence-based study was conducted at a large Veterans’ hospital located in the Southeastern United States. The study established that a set of care coordination strategies. The study employed a team-based case management approach involving a cardiologist, registered nurses, health services researchers, and research assistants (Shaw et al., 2014).

Conclusion 

In conclusion, it is demonstrable that improving the quality of care delivery for the homeless individuals with CHF results improved adherence to medication and reduced ED readmissions. Treatment of CHF among homeless and subsequent presentation to the emergency departments due to barriers associated with self-managing their health condition is an important health issue. This particular health issue is very important because members of the homeless population are at an increased risk for chronic cardiovascular conditions, including CHF. It is clear that heart disease is the leading cause of death among older men in the homeless population. The factors that have been identified to contribute to the increased risk of cardiovascular disease among the members in the homeless population include poverty, smoking, the high prevalence of inadequately managed conditions, and unhealthy diet. Socioeconomic deprivation has been closely associated with admission and readmission to emergency departments for CHF. The lack of medical adherence is a significant problem related to the management of CHF among the members of the homeless population. Homeless populations often have a difficulty accessing medication due to lack of money. Access to the medical care provider and transportation to pharmacies are also some of the barriers to effective medical care among homeless individuals. Therefore, implementing the intervention program will help in the effective treatment and management of CHF among the homeless in Dallas.

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