Preliminary Care Coordination Plan

Care coordination could be the most intensive intervention for caring for people with health and social needs. Care coordination organizes patient care and facilitates the delivery of safe and effective health care (Karam et al., 2021). As patient needs become complex, the efforts of care coordination play a substantial role in efficient care. Communication and multidisciplinary teamwork are what allow the delivery of effective care coordination.

Analysis of Homelessness Needs and Best Practices for Health Improvement

Being homeless is complex and challenging to address. An individual experiencing homelessness can have a negative effect on their health and access to health needs due to the limited access to primary healthcare (Canham et al., 2019). For example, someone experiencing homelessness goes to an emergency department for care; once the patient is treated, they are then discharged back to the street, which doesn’t allow any support recovery or access to follow-up care. This is an endless ongoing cycle of emergency room visits and using resources in healthcare systems (Sleet et al., 2021).

Homelessness is a major public health problem, and there needs to be access to self-care interventions for health improvement. It is essential to focus on the accessibility of quality self- care interventions is crucial for health improvement of individuals experiencing homelessness (Narasimhan et al., 2022). Self-care interventions would be the ability to prevent diseases, handle current illness, and maintain health. Physical considerations such as exposure to elements, malnutrition, and injuries make it difficult to provide effective self-care. Not having an address can lead to a multitude of health concerns, such as mental health issues, HIV, tuberculosis, and hepatitis. Living on the street also limits access to self-administration of medications or self-

monitoring, such as blood pressure or blood glucose checks, leading to hypertension and diabetes (Narasimhan et al., 2022).

Goals for the Homeless

Establishing goals is crucial to achieving health improvement in people experiencing homelessness. Goals need to be realistic, measurable, and attainable. According to the National Alliance to End Homelessness (NAEH), motivational enhancement therapy (MET) successfully achieves goals. MET is a goal-oriented counseling and case management style that supports and promotes lifestyle and behavioral changes. It is proven that MET improves the commitment to change and reduces problematic behaviors leading to homelessness (National Alliance to End Homelessness, 2023).

As I mentioned previously, exposure to elements hinders effective health improvement. Within one week, a person who is homeless needs to get connected with personnel from NAEH regarding Permanent Supportive Housing (PSH). This model provides safe housing and case management services to eligible individuals. Research shows that clients in PSH programs have an increase in housing stability (National Alliance to End Homelessness, 2023). Once housing is established, within one month, a primary care physician will be appointed for treatment and the establishment of self-care interventions. This will allow for regular checkups and treatments or prevention of chronic illnesses.

Community Resources for Safe and Effective Continuum of Care

Homelessness is a global public health problem that has increased every year for the last four years. There is some light at the end of the tunnel; community resources are available, and more is on the way. Utilizing community resources is a vital step in a coordination plan to ensure the continuity of care. Offering simple, quick tips such as dialing “211” will refer someone to

local services in their area, according to the National Health Care for the Homeless Council. This is a direct way to get help in any location.

An essential community resource is the Substance Abuse and Mental Health Services Administration, known as SAMHSA. This program offers evidence-based treatment and comprehensive and coordinated services for the homeless. As a care coordinator, it would be vital to provide applications for SAMSHA key programs they have to offer. Such as, treatment for individuals Experiencing Homelessness (TIEH) and Grants for the Benefit of Homeless Individuals (GBHI). Both of these programs have the goal of increasing access to evidence-based treatment and services.

Conclusion

Care coordination and collaboration with community resources are vital in order to tackle the health concerns that come with homelessness. As you can see, care coordination dialed in for each individual’s goals is necessary to fulfill health needs. Utilizing community resources is a simple intervention that greatly improves physical, health, psychosocial, and cultural needs. The resource can start with us nurses and being the patient advocates that we are.

References

Canham, S. L., Davidson, S., Custodio, K., Mauboules, C., Good, C., Wister, A. V., & Bosma,

H. (2019). Health supports needed for homeless persons transitioning from hospitals. Health & social care in the community, 27(3), 531–545. https://doi.org/10.1111/hsc.12599

Conway A, O’Donnell C, Yates P. The Effectiveness of the Nurse Care Coordinator Role on Patient-Reported and Health Service Outcomes: A Systematic Review. Evaluation & the Health Professions. 2019;42(3):263-296. doi:10.1177/0163278717734610

Hopkins J, Narasimhan M. Access to self-care interventions can improve health outcomes for people experiencing homelessness BMJ 2022; 376 :e068700 doi:10.1136/bmj-2021- 068700

Karam, M., Chouinard, M. C., Poitras, M. E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon,

C. (2021). Nursing Care Coordination for Patients with Complex Needs in Primary Healthcare: A Scoping Review. International journal of integrated care, 21(1), 16. https://doi.org/10.5334/ijic.5518

The National Alliance to End Homelessness. (2023). Our mission and history. https://endhomelessness.org/who-we-are/our-mission-and-history/

Sleet, D. A., & Francescutti, L. H. (2021). Homelessness and Public Health: A Focus on Strategies and Solutions. International journal of environmental research and public health, 18(21), 11660. https://doi.org/10.3390/ijerph182111660

Substance Abuse and Mental Health Services Administration. (2023). Homeless Programs and Resources. https://www.samhsa.gov/homelessness-programs-resources