The goals of this Doctor of Nursing Practice Project (DNP Project) are to provide equity in the provision of health care services for homeless persons on Maui, and improve how well their health care needs are met. The DNP Project is divided into Phase 1, Phase 2, and Phase 3. Phase 1 occurs during the course of the DNP Program. Phase 2 and Phase 3 will occur after the student has graduated from the DNP Program. The goal for Phase 1 of this DNP Project is to increase understanding of the unmet health care service needs of homeless persons on living Maui. A needs assessment in Phase 1 of the DNP Project will provide the information that will be a foundation for development of a plan in Phase 2. The goal for Phase 2 is to develop a plan to improve how well the health care needs of homeless persons living on Maui are met. During Phase 3, the plan will be implemented. The goal for Phase 3 is to implement the plan. Long term planned outcomes of Phase 3 for homeless persons living on Maui are: 1) an increase in access to primary care services; 2) a decrease in unnecessary emergency department visits; 3) decrease in acute care hospital lengths of stay and readmissions; 4) decreased health costs; and 5) improved quality of life. The Conceptual Model for this quality improvement project is the Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al, 2001), elements of the Diffusion of Innovation Model (Rogers, 2003) influence design of the project, features of the Logic Model (CDC, 2011) structure project evaluation of effectiveness.
The clinical question for the DNP Project is: “Among adult homeless persons on Maui, how do evidence-based interventions or evidence-based interventions with a nurse practitioner, compared to usual care, effect outcomes of met needs for healthcare services, access to primary care services, frequency of unnecessary emergency department visits, and acute care hospital lengths of stay?”. The literature review and synthesis documented potential solutions that are broad in scope, require stakeholder backing, involve system change, financial commitment, and are rolled out over a time period that exceeds the two years of the DNP Project. Turning from the grand view of what might be possible in the ideal setting, to what the evidence shows is a good approach for achieving incremental progress in two years is consistent with the concrete evidence-based practice change focus of the Iowa Model. According to the Iowa Model, if the answer to the question “Is there sufficient research to guide practice?” is “no”, the appropriate
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option would be to conduct a study. In this application of the Iowa Model the study is a needs assessment in Phase 1.
Overview of the DNP Project Phase 1
The goal for Phase 1 of the DNP Project is to increase understanding of the unmet health care service needs of homeless persons on Maui. Four process objectives pertain to this goal. One process objective of the DNP Project Phase 1 is a survey of 30 homeless persons on Maui. Thirty homeless persons on Maui will be asked to complete a survey to assess what their unmet health care needs are, what barriers to receiving services they experience including what their knowledge of available services is, what their use of available resources is, and what ideas for solutions they have for meeting their health care needs. A second process objective for Phase 1 is a survey of five key stakeholders in the care of the homeless on Maui. Five key stakeholders will be asked to complete a survey of what the unmet health care service needs of homeless persons on Maui are, what barriers homeless persons experience in receiving care, and what their ideas for solutions are. A third process objective for Phase 1 is a survey of groups of key
stakeholders involved in the care of homeless persons on Maui. Groups of key stakeholders will be asked to complete a survey of what the unmet health care service needs of homeless persons on Maui are, what barriers homeless persons experience in receiving care, and what their ideas for solutions are. Survey results will be analyzed. Results will be used to produce a report summarizing the needs assessment. The short-term outcome of Phase 1 is a needs assessment that will be used in Phase 2. The needs assessment will influence the planning and piloting of evidence-based outreach and inreach interventions in Phase 2.
Plan for Phase 1 Needs Assessment Evaluation
Overview of the Project plan. Evidence from the literature supports multidisciplinary mobile health outreach, inreach to facilities to improve access for homeless persons, medical respite options after discharge from acute care hospitalization, and increased housing
opportunities as interventions to meet unmet health care needs of homeless persons (Althaus et al. 2011; Fitzpatrick-Lewis et al, 2011; Howe et al, 2009; Hwang et al 2005; National Outreach Guidelines for Underserved Populations, 2012; O’Campo et al, 2009; O’Connell et al. ,2010; Schneller, 2012; Shortt et al. 2008).
A homeless person has been defined as a person without permanent housing who may live on the streets, stay in a shelter, mission, single room occupancy facility, abandoned building,
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or vehicle; or in any other unstable or non-permanent situation (HRSA, 2011). Unsheltered homeless persons have been distinguished from sheltered homeless persons. Unsheltered homeless persons reside in places not meant for human habitation such as vehicles, parks, sidewalks, abandoned buildings, and the street. Sheltered homeless persons reside in emergency shelters, or transitional or supportive housing for homeless persons who originally came from the streets or emergency shelters (HUD, 2004).
A community needs assessment that identifies the geographic area of the target population and barriers to accessing care for that target population is at the heart of any well planned program that matches services to needs in order to close gaps in care for the homeless. (National Health Care for the Homeless Council, 2014). A community needs assessment provides specific problem-focused triggers for use of the Iowa Model (Titler et al, 2001) and information about which of many potential interventions mentioned in the literature that would be feasible and effective.
The geographic area is the island of Maui. The target population is homeless persons on the island of Maui. The January 2013 Point-in-Time Count on Maui identified some 421
sheltered homeless persons and some 455 unsheltered homeless persons on Maui (State of Hawaii, May 2013). The January 2014 Point-in-Time Count on Maui showed 445 sheltered homeless persons, an increase of 5.70% from 2013, and 514 unsheltered persons, an increase of 12.97% over 2013 (State of Hawaii, May 2014).
This DNP Project is not a research project. It is an evidence-based practice quality improvement project. The evaluation of the evidence-based practice project will be a pre and post intervention design. The needs assessment, rather than a broad-based community needs assessment, will be specifically focused on topic areas. The needs assessment will include semi- structured interviews with individual key stakeholders in the care of homeless persons on Maui, with groups of key stakeholders such as hospital case managers and hospital social workers, and with 30 homeless persons themselves. The purpose is to identify unmet health care service needs, identify barriers to care including knowledge deficits, underutilization of services and other barriers, and identify possible solutions to unmet health care service needs. During Phase 2, after the student graduates from the DNP Program, interventions that increase access to primary care services will be planned. During Phase 3 interventions will be implemented. After the
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As part of the step of setting the direction for the assessment, it is important to consider both assets and needs (See Table 3.1), what is to be learned, and why this information is
important. It is important to consider if this information will move the project closer to the vision of homeless people with unmet health needs becoming housed people with met health care needs; where this information is, and if the information has already been collected (National Health Care for the Homeless Council, 2013).
The information to be learned is what the unmet health care needs are, what the barriers to accessing care are, and what solutions there might be. The reason this is important is to offer effective interventions to meet the needs. Some quantitative information for Maui has been collected in terms of numbers of homeless persons, use of available community services (U.H. Center on the Family, 2012), numbers of individuals treated at Malama I Ke Ola Health Center (HRSA, 2012). What apparently is not available is qualitative data from local key stakeholders, and from the homeless persons themselves. More particulars on data collection for this DNP Project are presented in the data collection section.
Lebrun-Harris et al (2013) examined the data of the 2009 Health Resources Service Administration (HRSA) Health Center Patient Survey and identified homelessness alone as a risk factor for unmet health needs among HRSA community health center patients. The data was collected nationally and the methods included computer assisted personal interviews with more than 2600 patients that lasted about 50 minutes each and gathered comprehensive quantitative data. Acosta and Toro (2000) commented that homeless service agencies have rarely relied on systematic needs assessments but, rather, have traditionally provided assistance to homeless persons according to what they intuitively believe are the basic needs of the homeless. They did a longitudinal study of 301 homeless persons. The initial needs assessment survey gathering quantitative data was about three hours in length. The follow-up survey was about two hours in length. For the purpose of this DNP Project, the interviews will be abbreviated by comparison to those two studies, by focusing selectively on more specific areas. The target time for the
interview will be 20 minutes.
Healthy People 2020 has identified access to health services as a leading health indicator (Healthy People 2020). One of the targets for this leading health indicator is 100% of the
population with health insurance. Another target is that 83.9% of persons have a usual primary care provider. Questions on the survey will address these health indicators. Questions will also
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include homelessness status. Answers to questions about homelessness status will clarify if the person is homeless or not to determine if the individual is part of the population to be surveyed, if the person is sheltered or unsheltered, and the duration of the person’s homelessness. The survey questions will address whether the person has health insurance, and a usual primary care provider; the person’s use of health care services including the number of emergency department visits in the last year, hospital stays, and the type of place the person stayed when discharged from the hospital. Another open-ended question will address the person’s unmet health care service needs. Possible categories of answers include: unmet needs for medical care, surgical care, or prescription medication; services for vision (e.g., for eyeglasses), dental care, or mental health or counseling; for substance abuse treatment, wound and skin care; and other needs. Another open-ended question will address barriers to accessing health care and related resources. Possible categories of answers include: knowledge deficit about available services, disinterest in use of available services, and inconvenient appointment times; difficulty with communication, (e.g., no phone), difficulty with transportation, or no insurance; no money for the co-pay, attitudes of those providing service, fears about receiving service; attitude of “I don’t care anymore”, competing priorities (e.g., for food, alcohol, or drugs, and other items).
Likely program components that will be planned in Phase 2, and implemented in Phase 3 include health outreach which includes assisting persons who are not yet signed-up for medical insurance to sign-up, and addressing common health care concerns that can be addressed in a simplified outreach setting such as wound care, in addition to concerns broached in the survey. Inreach interventions are likely to include working with providers to develop services adapted to the needs of homeless persons (e.g., appointment times), navigators to facilitate access, and education about the culture of homelessness.
During Phase 3 post intervention surveys will be done. Pre-intervention and post- intervention data will be compared and analyzed. Those who experience interventions during Phase 3 will be surveyed about the intervention. Results will be used to modify Phase 3
interventions. Interventions for this DNP Project also include actions to support development of multidisciplinary health outreach associated with a health clinic, housing initiatives, and medical respite. The three semi-structured surveys are included in Appendix A. Assets in the community include items in Table 3.1.
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Goals and objectives for project evaluation. The goals for this DNP Project are to provide equity in the provision of health care services for homeless persons living on Maui, and improve the provision of health care services to meet homeless persons’ needs. The goal for Phase 1 of the DNP Project is to increase understanding of the unmet health care service needs of homeless persons living on Maui.
The outputs for Phase 1 of this project evaluation are as follows: quantitative and qualitative needs assessment on homeless needs for health care services and access to primary care services with 30 homeless persons, five key stakeholders, and two stakeholder groups in Phase 1 in spring of 2015.
Table 3.1. Assets in the Community for Health Care for the Homeless
Type of Asset Name of Organization
Outreach Services Salvation Army
A Cup of Cold Water Mental Health Kokua
Community Health Center Malama I Ke Ola Health Center Satellite Services in Lahaina
Satellite Services at Ka Hale A Ke Ola Homeless Resource Center
Hospital Maui Memorial Medical Center
Shelters Ka Hale Ake Ola Homeless Resource Center
Family Life Resource Center Kahului Women Helping Women
Hygiene Salvation Army, Kahului
Nutrition and Meals Maui Food Bank
Salvation Army, Kahului
St. Teresa Church Hale Kau Kau, Kihei Good Shepherd Church, Wailuku
The process objectives for Phase 1 output 1 appear in Table 3.2 and are as follows: the DNP student, during 2015, will perform a semi-structured mixed methods survey of a purposive sample of 30 homeless persons on Maui to assess their met and unmet health care service needs; perceived barriers to obtaining health care services; and ideas about interventions that would help them meet their health care service needs; the DNP student, during 2015, will perform a semi-structured qualitative survey conversation with a purposive sample of five knowledgeable stakeholders about homeless persons’ on Maui met and unmet health care service needs; barriers to obtaining health care services; and their ideas about interventions that would help homeless
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persons on Maui meet their health care service needs; the DNP student, during 2015, will perform a semi-structured qualitative survey conversation with two groups of key stakeholders involved in the care of homeless persons on Maui about homeless persons’ met and unmet health care service needs; barriers to obtaining health care services; and their ideas about interventions that would help homeless persons living on Maui meet their health care service needs; and the DNP student utilizes the survey results, in combination with the DNP Project literature synthesis, and expert consultation, to draw conclusions about unmet health care service needs, barriers to care, and ideas for solutions. The short-term outcome is a needs assessment report. This is addressed in Table 3.3.
Phase 2 begins following the student’s graduation from the DNP Program. The goal for Phase 2 is to develop a plan to meet homeless persons unmet health care service needs. A preliminary plan that will be modified after the needs assessment report is completed during Phase 2 is included later in this document. Supplemental materials can be found in Appendix B: Phase 2 and Phase 3. See Table B.1 Phase Medium Term Outcome in Appendix B-1. Phase 3 follows Phase 2. The goal of Phase 3 is to improve how well health care service needs for homeless persons on Maui are met and increase health equity. During Phase 3, post intervention survey data will be collected and compared to data collected during Phase 1. See Tables B.2 Phase 3 Goals Output 2, and Table B.3 Phase 3 Goals Output 3 in Appendix B-2.
The outputs for Phase 3 are quantitative and qualitative needs assessment on homeless needs for health care services and access to primary care services following provision of health outreach and inreach services, with open-ended questions about further ideas for solutions. Surveys will be conducted with 30 homeless persons, five key stakeholders, and two stakeholder groups during 2016. Data will be analyzed, results identified, and conclusions drawn to modify outreach and inreach interventions. The Logic Model in Table 3.7 lays out the structure and connections of the phases of the Project.
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Table 3.2 PHASE 1 GOAL: Increase Understanding of Unmet Health Care Service Needs of Homeless Persons on Maui
Outputs SMART Objectives
Evaluation data
Timeframe Measure Baseline Target Data Source
OUTPUT 1 Conduct quantitative and qualitative needs assessment on homeless needs
PROCESS OBJECTIVE1The DNP student, during 2015, will perform a semi-structured mixed methods survey of a purposive sample of 30 homeless persons on Maui to assess their met and unmet health care service needs; perceived barriers to obtaining health care services; and ideas about interventions that would help them meet their health care service needs. Number of surveys administered No baseline available. This is Phase 1 pre- intervention survey. 30 surveys Mixed methods face- to-face survey Spring 2015
PROCESS OBJECTIVE 2 The DNP student during 2015, will perform a semi-structured qualitative survey with a purposive sample of 5 knowledgeable stakeholders about Maui homeless persons’ unmet health care service needs; barriers to obtaining health care services; and their ideas about interventions that would help homeless persons on Maui meet their health care service needs.
Number of Qualitative face-to-face survey of view of homeless persons unmet needs, barriers, ideas for solutions No baseline available. This is Phase 1 pre- intervention survey. 5 interviews Qualitative face-to-face survey Spring 2015
PROCESS OBJECTIVE 3 The DNP student during 2015, will perform a semi-structured qualitative survey
conversation with two groups of key stakeholders involved in the care of homeless persons on Maui about homeless persons’ on Maui met and unmet health care service needs; barriers to obtaining health care services; and their ideas about interventions that would help homeless persons on Maui meet their health care service needs.
Number of Qualitative face-to-face group survey of view of homeless persons unmet needs, barriers, ideas for solutions No baseline available. This is Phase 1 pre- intervention survey. 5 interviews Qualitative face-to-face group survey Spring 2015
PROCESS OBJECTIVE 4 The DNP student will analyze the survey results, in combination with the DNP PROJECT literature synthesis, to draw conclusions about unmet health care needs, barriers to receiving care, and ideas for solutions