Introduction – Finding a path
Planning for a safe discharge from hospital is part of every patient care journey and starts at the time of admission. It is the responsibility of the multidisciplinary care team to coordinate a discharge plan with the patient that aligns community support systems and not only identifies but addresses anticipated barriers. For patients experiencing homelessness in rural Alberta the discharge plan can be significantly more complex and barriers can result in delayed discharge or expeditious readmission. I work in a rural Alberta hospital setting providing care for and planning discharges for patients who are experiencing homelessness. There has been a significant increase in complexity of identified discharge barriers and in frequency of patients who present with unsustainable housing. Approximately 0.37 per cent of Alberta’s rural population is experiencing homelessness or housing instability, a number that increases to one per cent when counting other affected adults and children who share the unstable housing (Herring, 2020). This statistic highlights the demand for coordinated discharge planning that needs to be led by a collaborative multidisciplinary care team inclusive of the hospital healthcare providers, community resource stakeholders, and the patient.
There is no set clinical care pathway for discharging a patient who is experiencing homelessness and there is no defined decision-making algorithm to outline discharge planning for a patient experiencing homelessness in Rural Alberta. There is no consistent resource allocation from town to town and no set structure to facilitate the multifaceted discharge planning process. To create structure and tangibly explore this health issue further I will apply a multilevel health model to serve as a framework for the discharge planning clinical care pathway that can serve as a decision-making algorithm for the multidisciplinary care team to coordinate a consistent approach for the implementation of a successful discharge plan when supporting a patient experiencing homelessness in Rural Alberta.
Multilevel Health Model – National services population model
The National Health Services population health framework for healthcare providers (2021) is a multilevel health model that can be applied to coordinate a collaborative, inclusive discharge plan for a patient experiencing homelessness in rural Alberta by supporting the multidisciplinary care team to organize, prioritize, and strategize. I have chosen this model as it is simplistic in design and flexible in function. The infographic displays the multiple, integrated influences that collaboratively work together. I appreciate how the inner connected pies are organized into themes that are crusted by concepts and supported by a uniform commitment of collaborative working:
Collaborative working
The uniform outer ring is representing the multidisciplinary care team and the collaborative commitment to the work in progress. In applying this to discharge planning for a patient experiencing homelessness this outer circle is the collective cohesion of hospital, community, and patient stakeholders. Clinicians have a special role to play in ensuring that real-world efforts to address social determinants of health truly improve individuals’ health and wellbeing, promote informed choices, and support health equity (DeCamp, DeSalvo, & Dzeng, 2020).
Population healthcare and health services
This pie sector focuses on the overarching value of healthcare services, the public perception and relies on using data and evidence for integrating into decision. There is emphasis for reflection on health care service delivery that includes effectiveness, quality, and safety. These are all important considerations for the multidisciplinary team to consider in coordinating discharge planning for patients experiencing homelessness and offer an opportunity to incorporate the patient experience into consistency within federal funding, provincial policy making and regional resource prioritization. For example, in Alberta, Alberta Health Services (AHS) in collaboration with patient advocates developed, AHS Home to Hospital to Home Transitions Guideline as depicted in this high-level infographic:
Health Protection
For the multidisciplinary team engaged in discharge planning coordination is essential in preparing the patient for a sustained discharge. The multidisciplinary care team must include emergency planning that links to community resources and work with the patient to prioritize any additional health concerns that could require screening, immunizations, and facilitate access to coordinated outpatient healthcare services. Identifying any concerns with infection, prevention, and control needs due to housing and access to resources that help to support the basic activities of daily living within the community. Because, if these multiple barriers are not incorporated into the plan and coordinated than for those patients’ experiencing homelessness are at greater risk when unsafely discharged from hospital to situations which may put their health at further risk (Coleman, 2013).
Community role and wider determinants
Patients who are experiencing homelessness have a need for stable housing as it is the foundational barrier that has the potential to block discharge, delay transitions and reset a recurrence for readmission. This pie element focuses to reducing health inequalities, provide equitable access, foster sustainability, employment practices and procurement. I found this infographic developed by the United States Interagency Council on Homelessness that depicts the cycle of chronic homelessness (2016):
Permanent housing is displayed at the core that helps to break the chronic homelessness cycle. Having access to stable, permanent housing is a significant impact to a patients discharge from hospital. In many of the smaller rural communities there is no or limited availability resulting in discharge plans that remove patients from their communities. And as varying levels of government come to realize the extraordinary healthcare costs associated with homelessness, strategies for hospital discharge planning which focus on housing first approaches have become increasingly common (Coleman, 2013).
Prevention and health improvement
The last piece of pie reinforces the need for healthy environments. There is emphasis on patient interventions and healthy cultures. In many locations, rural communities have limited services available to address homelessness locally, thus migration to larger centers is often relied on as a mitigation strategy. However, significant community-based responses which draw on available formal and informal support systems do exist to address local needs (Waegemakers & Turner, pg 6, 2014). There is often no emergency shelter, transitional housing, or adequate affordable housing in place. (Waegemakers & Turner, pg 32, 2014) and the plans are not replicated or repeatable. It is important for the multidisciplinary care team in considering discharge to not underestimate the importance for a patient to stay within the rural community even though the access to certain resources may be different there may be greater priority based on healthy community supports and local interventions.
Conclusion - The Safe Path Home
National Health Services population health framework for healthcare providers (2021) has given me the opportunity to apply this multilevel health model tangibly to coordinate a collaborative, inclusive discharge plan for a patient experiencing homelessness in rural Alberta. The model serves as a flexible, functional algorithm by supporting the multidisciplinary care team to organize, prioritize, and strategize discharge decision making that is patient centered. There is significant opportunity for the development of a coordinated, collaborative discharge plan that is inclusive of hospital and community resources recognizing the need to ensure a safe discharge that includes stable housing, connection to community resources and coordinated access to healthcare services. Not only will hospitals be acting morally and socially responsible while saving money, but they will also be positively contributing to local efforts to prevent homelessness, and to the promotion of the health and well being of patients who have been experiencing homelessness (Coleman, 2013).
I have had the immense privilege to collaboratively work with multidisciplinary care teams who have been creative, coordinated, and intentional in coordinating realistic, patient centered discharge plans for those experiencing homelessness. But each example is unique, each service accessed, or community resource leveraged is specific to that moment in time and availability. Waegemakers & Turner, (2014) argued for the need to develop regional and systematic approaches to rural homelessness as part of an intentional Alberta response. This would include coordinating resources and developing systemic regional strategies as well as the tailoring of strategies to groups of communities with similar challenges in service delivery. Include a comprehensive housing and service infrastructure plan to address housing instability in smaller centers as part of a broader Alberta response. This co-ordination needs to occur at the regional, provincial, and federal levels (p. 6).
References
Alberta Health Services. (2020). Primary health care integration network: Home to hospital to home transitions guideline. Retrieved November 6, 2021, from https://www.albertahealthservices.ca/assets/info/hp/phc/if-hp-phc-phcin-hthth-guideline.pdf
Coleman, A. (2013). Hospital discharge safe and effective models for people experiencing homelessness. Retrieved October 22, 2021, from
DeCamp, M., DeSalvo, K., & Dzeng, E. (2020). Ethics and spheres of influence in addressing social determinants of health. Journal of General Internal Medicine, 35(9):2743–5. Retrieved October 21, 2021 from https://link.springer.com/article/10.1007/s11606-020-05973-1
Herring, J. (2020). Rural homelessness in Alberta a 'hidden crisis': new study. Retrieved October 23, 2021, from
National Health Services. (2021). Population health framework for healthcare providers. Retrieved October 20, 2021, from
United States Interagency Council on Homelessness. (2016). Cycle of chronic homelessness. Retrieved October 22, 2021, from Cycle-of-chronic-homelessness.png (1438×847) (usich.gov)
Waegemakers, J., & Turner, A. (2014). Rural Alberta homelessness (pp. 6, 32). Retrieved October 23, 2021, from Rural Alberta Homelessness
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