1. UNIVERSITY OF WASHINGTON
Improved Patient Outcomes
Meeting the needs of homeless patients with overutilization of the ED
Jacquelyn M. Pinkerton
3/12/2015
People who are homeless have to depend on a variety of emergency services to meet their needs
which has created a vicious cycle of service utilization that is difficult to break. Being homeless can
create a constant state of crisis; this state of crisis is perpetuated by not being able to meet basic needs,
feelings of isolation, feelings of fear,as well as compounding loss of social connections, job, and health
(Clarke, Williams, Percy,& Kim, 1995). Current health systems lack services designed to meet the needs
and complexity of homeless persons and this inadequacy enables the use of the emergency room as these
peoples’ needs continue to go unmet (Parker & Dykema,2013). The research indicates a need for better
interpersonal, interdepartmental, and interagency collaboration to do more to increase efficacy of initial
interventions and improved preventative measures to reduce unnecessary readmissions.

2. Pinkerton: Improved Patient Outcomes
2
Jacquelyn Pinkerton
Improved outcomes for homeless patients who use the ED to meet their basic needs
TSOCW 533 Advanced Integrative Practices
Teresa Holt, MSW, LICSW
March 12, 2015

3. Pinkerton: Improved Patient Outcomes
3
Contents
Introduction .......................................................................................................................................4
Proposed assessment tool: Initial Encounter in ED................................................................................6
Subsequent Encounters .......................................................................................................................7
Supplemental Activities ......................................................................................................................8
Logic Model Template........................................................................................................................9
Data Collection Worksheet................................................................................................................10
Description of Project .......................................................................................................................12
Background......................................................................................................................................13
Risk/Priorities ..................................................................................................................................17
Bibliography ....................................................................................................................................19
Problem Map....................................................................................................................................20
Force Field Analysis .........................................................................................................................20

4. Pinkerton: Improved Patient Outcomes
4
Introduction
I am proposing a designated position, within the hospital setting, that aims to meet the
needs of our most vulnerable patient population, namely homeless patients with high-utilization
of Emergency Department (ED) services. The short term goals are to improve patient knowledge
of community resources and improve patient access to these community resources. Looking to
the future, the long-term goal of this position is to eliminate the use of the ED by homeless
patients to meet their basic needs (eg. food, shelter, clothing, transportation etc.). These goals
necessitate that ED systems engage in interagency and interdepartmental collaborations to
connect homeless patients to providers who can meet their basic needs as evidenced by decrease
use of the emergency department. The characteristics of this proposed position include
acknowledging the dignity and worth of a person, cultivating human relationships, behaving in a
trustworthy manner, and providing services that are socially just (Martin, 2014; Parker &
Dykema, 2013; Reitz-Pustejovsky, 2002). It is important to provide real time referrals and
interventions specific to the individual being served as this approach is more effective and aligns
with NASW and agency ethical principles (Parker & Dykema, 2013).
NASW guidelines and Citizenship theory are the guiding framework for meeting the
needs of homeless patient’s utilizing the ED for non-emergencies. For these patients who are our
most vulnerable, an effective intervention must consider a theoretical framework that addresses
the relationship between justice and attachment; interventions must be meaningful for those
receiving care more than being for the person or agency offering care (Reitz-Pustejovsky, 2002).
Citizenship theory incorporates both justice and attachment by looking at the individual within
the community and whether they are represented and treated as citizens rather than being
relegated as an ‘other’. ‘Just’ care cannot be done without promoting attachment between
marginalized people and the mainstream community of which they are a part (Reitz-Pustejovsky,
2002). Citizenship theory emphasizes the agency of the individual and values the dynamic
between individual and community; when people are pushed further away from being a part of a
community they are treated as less than full citizens and subjected to subsequent injustices.
Sanabria (2006) applies attachment theory as it relates to an individual’s attachment to their
community and suggests if there is poor attachment then there are associated risks including a
minimized sense of belonging, poor outcomes for public health and increased rates of violence
and poverty. Citizenship theory reframes the conversation around homelessness by valuing the

5. Pinkerton: Improved Patient Outcomes
5
individual members’ and their potential contributions to society and opens the conversation to
the opportunity of community building to address a social issue (Reitz-Pustejovsky, 2002).
Finally, citizenship theory also provides a framework for treating within a psycho-social context
(Rowe, Kloos, Chinman, Davidson, & Cross, 2001). By operating within this framework we will
address the strengths and needs of the individual while collaborating with the larger community
to improve outcomes.
By implementing a designated position to facilitate continuity of care following ED
discharge, the anticipated outcomes include improved patient knowledge of community
resources and improved patient access to services. An assumption of this proposal is that
homeless patients are brought to the ED, voluntarily or involuntarily, because they have basic
needs that are not being met in the community. By utilizing the designated case worker in real
time we can identify the most emergent needs and actively implement referrals rather than
provide patients with a handful of generic resources and send them on their way. In addition to
the direct services provided to patients, this position must also cultivate and maintain community
partnerships to ensure a smooth transition for referrals. When providers collaborate, rather than
operate siloed within their agency, they can more effectively meet the needs of the patient by
mitigating the risk of losing them in the transition and also by reducing inefficiencies of
duplicative work inherent in repeat data collection. In addition to the individual patient outcomes
this intervention will also free up ED beds, provide cost savings to the hospital by reducing
readmission of patients whose services may not be reimbursable, and improve relationships with
community partners who can meet the needs of these patients in an outpatient community
setting.

6. Proposed assessment tool: Initial Encounter in ED
Encounter Date: Record the date of first encounterwith patient
Patient Name: Lat name, First Name Patient Number: Systemgenerated patient ID #
Means ofArrival: Indicate howthe patient arrived in the ED at current encounter. Consider looking at previous ED
admissions and patient meansof arrival, this may informsubsequent intervention as it relates to barriers and indicated
(in)voluntary use of ED.
Presenting Problem: Record the presenting problemupon arrival.
Secondary Problem(s): Ask the patient if there are additional problems not addressed in previous section.
Patient Goals for Treatment: What are the patient’s treatment or outcome goals. Is the patient amenable to
service/intervention?
Needs or Barriers: Indicate patient self-reported needsor barriers preventing access to services or treatment.Case
Worker can inferadditional items but should validate with patient for accuracy.
Mental Health
Services
Case Management Counseling Rx Management
Medication Prescriber Access Coverage Management
Food Food Stamps Local Food Banks Hot Mealproviders
Shelter Case Management Physical Shelter
Transportation Bus Pass Taxi Scrips Gas Card
Communication Telephone Voicemail Email Mailing
Address
Storage
Other, specify
Strengths and Informal Supports: Identify patient strengths and informal supports available to meet identified goals.
Case Manager
Family, friends
Spiritual Congregation
Community Group
Support Group
Other, specify
Next Steps: What are the next steps within the 1st
week of encounter.How will Case Worker and patient reconnect?

7. Subsequent Encounters
Within 7 days of initial ED Encounter.
ReviewInitial Assessment Make adjustments to action plan and implement identified next steps.
Implement action plan within first 30days. Ensure that patient has made connections with community
service providersor identified case managers.
Follow-up with patient at 3/6/12 month intervals to monitor progress and facilitate ongoing
implementation ofplan. Make changes to the plan as needed based on patient’schanging psycho-social
context, survey responses,and 1:1 interview.
Administer survey prior to face to face and discuss during appointment.
1. What are your needs (for example: shelter, food, personal hygiene, clothing, storage,
telephone/internet, transportation, medical follow-up, dental, counseling, employment services,
case management)
a. _____________
b. _____________
c. _____________
2. Where can you go to meet the needs you listed?
a. _____________
b. _____________
c. _____________
3. Who can you contact to attain resources?
a. _____________
b. _____________
4. Who can help you attain community resources if you are unable to access them independently?
____________________________________________________________________________
Interview:Review action plan established at initial intake. Discuss patient gaps in knowledge about their
individual action plan. Ask patient if their needs are being met.
Case Records:Review hospital EDIE report and patient encounter record. Discuss outcomes or record
with patient during interview.
1. Made necessary appointment (indicate type of services):
a. Service __________________Appointment Date _______________ Attended/Missed
i. Reason missed(if applicable) _________________________________________
b. Service __________________Appointment Date _______________ Attended/Missed
ii. Reason missed(if applicable) _________________________________________
c. Service __________________Appointment Date _______________ Attended/Missed
iii. Reason missed(if applicable) _________________________________________

8. Pinkerton: Improved Patient Outcomes
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Supplemental Activities
Establish and maintain Memorandums ofUnderstanding (MOUs) with community partners. MOUs
to be established with community providers who provide services relevant to our target population.
Work with IT Specialist to improve resource database; monitor accuracy ofdatabase on a monthly
basis to ensure efficient referrals.
Meet with community partners quarterly to discuss what is working in the referral process and
identify areas for improvement.

9. Logic Model Template
Needs Statement: ED systems need to engage in inter-agency/interdepartmental collaborations to connect homeless patients to providers who can meet
their basic needs as evidenced by decrease use of the emergency department.
Theoretical Influences and Assumptions: Citizenship theory is the guiding framework for meeting the needs of homeless patient’s utilizing the ED for
non-emergencies. This theory emphasizes the agency of the individual and values the dynamic between individual and community. By operating within this
framework we will address the strengths and needs of the individual while collaborating with the larger community.
RESOURCES ACTIVITIES
(Process Objectives)
OUTPUTS*
(Outcome/Summative
Objectives)
OUTCOMES
(Short term goals)
*OUTCOME
INDICATORS
(Outcome/Summative
Objectives)
LONG TERM
GOAL
 Funding for new
position
 Funds to invest
in possible
community
placement or
referral settings
(designated beds
or one night
stays)
 Agency vehicle
to provide client
transportation or
mileage
reimbursement
 Tech support
and updated
resource list
 Create
Memorandums Of
Understanding
(MOU) with partner
agencies
 Maintain
partnerships with
MOU’s
 Develop initial
process with case
worker for referral
 Case worker ensures
follow-up with
community agency
 Hospital designated
case worker
 Improved database
with map of
community
resources
 MOU’s with
shelter/food/resource
providers within the
Auburn community
 Quarterly roundtable
with partners to
address service referral
issues
 Increase meeting of
patient’s basic needs
through effective
referral process and
action plan
 Free up ED beds
 Online interactive
resource map
Outcome 1: Improved
knowledge of community
resources.
Outcome indicator 1a:
Knows who to contact to
attain community
resources.
Outcome indicator 1b:
Knows how to get
community resources.
The long-term
goal is to
eliminate the use
of the Emergency
Department by
homeless patients
to meet their
basic needs (eg.
Food, shelter,
clothing,
transportation
etc.)
Outcome 2: Improved
access to services
Outcome indicator 2a:
Accesses services that
meet needs.
Outcome indicator 2b:
Implements action plan
to meet service needs
with other community
resources.

10. Pinkerton: Improved Patient Outcomes
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Data Collection Worksheet
OUTCOMES/CRITERIA TOOLS
DATA
COLLECTION
PROCESS
DATA
COLLECTION
METHOD
VALIDITY
Outcome 1: Improved knowledge of community
resources. Criteria: Patient has achieved outcome
indicators 1a and 1b.
Outcome indicator 1a: Knows who to contact to
attain community resources. Criteria: Patient can
identify their needs and appropriate resources to
meet those needs on a survey.
Outcome indicator 1b:
Knows how to get community resources.
Criteria: Patient is able to indicate on the survey
how to access services to meet their basic needs.

Outcome 1 Tool:
Survey: Objective
measurement of whether
patient possesses the
knowledge that indicates
progress or competence.

Collected at initial
appointment and final
appointment.

Gather data on all
clients.

 Peers and key
stakeholders are able
to identify the
purpose of the
questions being asked
 Participants respond
appropriately
 Participants
consistently respond
appropriately
 Data supports
participant responses
Outcome 2: Improved access to services. Criteria:
Patient has achieved outcome indicators 2a and 2b.
Outcome indicator 2a: Accesses services that meet
needs. Criteria: Patient is able to self-report where
there needs have been met and there will be a
decreased incidence of ED utilization.
Outcome indicator 2b: Implements action plan to
meet service needs with other community resources.
Criteria: During interview patient can articulate the
action plan and whether that plan has led to their
basic needs being met.
Outcome 2 Tool:
Interview with patients:
Their subjective
understanding of behavior
competence.
Case Records: Objective
tool to evaluate patient’s
previous use of
inappropriate services
compared to current use of
appropriate services.
Case worker collects
this information at
final appointment and
then 3/6/12 month
follow-up intervals.
Check ED reports.
Provide case worker
contact information
to patients and
encourage patient to
follow up. Have
patient sign consent
to view future
records.
RELIABILITY

11. Pinkerton: Improved Patient Outcomes
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Outcome 1: Improved knowledge of community resources. Outcome indicator 1a: Knows who to contact to attain community resources. Criteria: Patient
can identify their needs and appropriate resources to meet those needs on a survey. Outcome indicator 1b: Knows how to get community resources.
Criteria: Patient is able to indicate on the survey how to access services to meet their basic needs.
Survey (administer survey prior to face to face and discuss during appointment)
5. What are your needs (for example: shelter, food, personal hygiene, clothing, storage, telephone/internet, transportation, medical follow-up, dental,
counseling, employment services, case management)
a. _____________
b. _____________
c. _____________
6. Where can you go to meet the needs you listed?
a. _____________
b. _____________
c. _____________
7. Who can you contact to attain resources?
a. _____________
b. _____________
8. Who can help you attain community resources if you are unable to access them independently?
____________________________________________________________________________
Outcome 2: Improved access to services. Outcome indicator 2a: Accesses services that meet needs. Criteria:Patient is able to self-report where there
needs have been met and there will be a decreased incidence of ED utilization. Outcome indicator 2b: Implements action plan to meet service needs with
other community resources. Criteria:During interview patient can articulate the action plan and whether that plan has led to their basic needs being met.
Interview:Review action plan established at initial intake. Discuss patient gaps in knowledge about their individual action plan. Ask patient if their needs
are being met.
Case Records:Review hospital EDIE report and patient encounter record. Discuss outcomes or record with patient during interview.
2. Made necessary appointment (indicate type of services):
a. Service __________________Appointment Date _______________ Attended/Missed
iv. Reason missed(if applicable) _________________________________________
b. Service __________________Appointment Date _______________ Attended/Missed
v. Reason missed(if applicable) _________________________________________
c. Service __________________Appointment Date _______________ Attended/Missed
vi. Reason missed(if applicable) _________________________________________

12. Pinkerton: Improved Patient Outcomes
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Description of Project
The following proposal is a micro-level intervention aimed at serving homeless
patients who over utilize the hospital Emergency Department (ED) to meet their basic needs.
This intervention requires a designated case worker who can meet patients where they are at,
conduct a holistic psycho-social assessment to identify their strengths and needs, develop an
individual action plan, connect these patients with providers in our community for ongoing
support, and provide follow-up to ensure successful implementation of their individual action
plans. Not only will this proposed intervention improve outcomes for the patients being
served but it will reduce fiscal losses incurred by the hospital for rendering services that may
or may not be reimbursed. Over-utilization of the ED by patients, specifically homeless
patients, requires an intervention that connects the individual to the larger community in
order to break the cycle of: ED utilization for immediate crisis relief, rapid discharge, and
subsequent return to the ED.
Our target population consists of those patients who are repeatedly admitted to the
ED because their basic needs are not being met in the community. Basic needs may include
shelter, food, security, stability, medical, and/or mental health treatment. Some of these
patients come to the ED voluntarily while others are brought to the ED involuntarily. For
these patients who are our most vulnerable, an effective intervention must consider a
theoretical framework that addresses the relationship between justice and attachment.
Interventions must be meaningful for those receiving care more than being for the person or
agency offering care (Reitz-Pustejovsky, 2002). Citizenship theory incorporates both justice
and attachment by looking at the individual within the community and whether they are
represented and treated as citizens rather than being relegated as an ‘other’. ‘Just’ care cannot
be done without promoting attachment between marginalized people and the mainstream
community of which they are a part (Reitz-Pustejovsky, 2002). Citizenship theory
emphasizes the agency of the individual and values the dynamic between individual and
community; when people are pushed further away from being a part of a community they are
treated as less than full citizens and subjected to subsequent injustices. When trying to meet
the needs of those being served it is unjust to leave them out of the conversation because they
do not have the economic privilege to interject themselves into the conversation (Sanabria,
2006). Sanabria (2006) applies attachment theory as it relates to an individual’s attachment to

13. Pinkerton: Improved Patient Outcomes
13
their community and suggests if there is poor attachment then there are associated risks
including a minimized sense of belonging, poor outcomes for public health and increased
rates of violence and poverty. Citizenship theory reframes the conversation around
homelessness by valuing the individual members’ and their potential contributions to society
and opens the conversation to the opportunity of community building to address a social
issue (Reitz-Pustejovsky, 2002). Finally, citizenship theory can also provide a framework for
treating within a psycho-social context (Rowe, Kloos, Chinman, Davidson, & Cross, 2001).
I propose that we allocate resources for a designated case worker to meet the
individual needs of our target population that allows for continuity of care following
discharge therefore improving outcomes and reducing overall costs to the hospital. This case
worker would have improved access to resource database information and be responsible for
maintaining memorandums of understanding (MOU’s) with partner agencies to facilitate
implementation of patient’s individual action plans. Anticipated outcomes of this
intervention include better outcomes for our patients, freeing up ED beds, and cost savings to
the hospital by reducing readmission of patients whose services may not be reimbursable. We
will also have improved relationships with community partners who can meet the needs of
these patients outside the scope of services available in the ED.
Values and ethical considerations guiding this intervention include acknowledging
the dignity and worth of a person, cultivating human relationships, behaving in a trustworthy
manner, and providing services that are socially just (Martin, 2014; Parker & Dykema, 2013;
Reitz-Pustejovsky, 2002). It is important to provide real time referrals and interventions
specific to the individual being served as this approach is more effective and aligns with
NASW and agency ethical principles (Parker & Dykema, 2013).
Background
The needs identified to address the problem of overutilization of the ED for non-
emergencies include needed resources and changes in ED practice. Resources that are needed
include tools for service providers to more efficiently identify/organize what is available to
meet patients’ needs within the context of their own limitations. Hospital organizations could
utilize fiscal resources to reserve crisis beds and/or fund community shelters to increase
capacity in the community and decrease reliance on ED beds. Without necessarily putting
money directly into the community, organizations may benefit from having a staff person

14. Pinkerton: Improved Patient Outcomes
14
who specializes in knowing what resources are available and maintaining MOUs with those
providers. There is a need for someone to be available outside of normal business hours to
implement intervention and prevention strategies for ED high-utilizers. This designated role
could address emergency and long-term intervention needs for the including care
coordination, supporting those most at risk, and strengthening relationships between agencies
(Kutza & Keigher, 1991). Outreach is important component to meet the needs of a population
that faces barriers as ‘simple’ as a front door (Martin, 2014; McDougal-Treacy, 2014).
Finally, there is a need to break down the barriers that lead to providers working within
individual silos thus reducing the efficacy of care and collaboration. Applebee (2014)
discussed the challenges of effective intervention in the emergency rooms because medical
staffs have a priority to meet the emergency medical needs of patients and this requires that
referrals be made to other ED staff for ongoing follow-up or intervention. While it makes
sense that medical staffs do not have the time to do individual intervention there is room for
improvement as far as collaboration between roles and effectively meeting the patients’
needs. Increased collaboration in connecting homeless patients with community providers is
a potential need due to a common misperception that homeless people are especially mobile
and not likely to follow-up with outpatient care (Parker & Dykema, 2013).
Homelessness is not a new issue and it impacts readmission rates within emergency
departments by the chronically ill and mentally ill due to an ongoing lack of adequate
community supports and shelter (Rosenfield, 1991). Homelessness has and continues to
evolve based on changing social and economic climate. For example, in the 1980’s there was
a social and political shift that resulted from unintended consequences of
deinstitutionalization of the mentally ill, ‘War on Poverty’, and establishment of minimum
wage (Clarke, Williams, Percy, & Kim, 1995). These social policy changes were designed to
reintegrate the mentally ill into the community, establish a safety net, and combat a social
issue that had a resurgence of public visibility and attention. Deinstitutionalization was
especially detrimental in that it took away basic needs like shelter, regularly scheduled meals,
accessible mental health and medical providers, and stability without creating community
supports to provide continuing care (Kutza & Feigher, 1991; Rosenfield, 1991). Socially
there is a general consensus that the issue of homelessness requires intervention but as a
collective we lack the conviction to hold ourselves accountable to meeting this need.

15. Pinkerton: Improved Patient Outcomes
15
Homeless people are a vulnerable population and those with the social and political power
have a responsibility to advocate for justice on behalf of those without power (Reitz-
Pustejovsky, 2002). In addition to our social responsibility to address the problem of
homelessness we also need to change our attitudes towards the homeless population. We
create artificial standards for those who are deserving of help, like veterans, women and
children, and those who are undeserving like men, immigrants, and drug addicts; these
artificial lines blur our vision and treatment of these people and create unnecessary hurdles in
trying to initiate change. Trying to judge those deemed unworthy and mandating that they
change their individual behaviors isolates them from mainstream society thus perpetuating
stigma and a cycle of victim blaming (Laakso, 2013).
Regardless of the time period, some similarities identified in the past and present
homeless populations include extreme poverty, mental illness and/or chemical dependency,
physical disability, social isolation, and reliance on shelters, food banks, community health
clinics, and clothing banks to meet their basic needs (Rossi, 1990). This population has to
depend on a variety of emergency services to meet their needs and it has created a vicious
cycle of service utilization that is difficult to break. Being homeless can create a constant
state of crisis as individuals are unable to cope as a result not knowing how they are going to
meet their most basic needs, feelings of isolation, feelings of fear, as well as compounding
loss of social connections, job, and health (Clarke, Williams, Percy, & Kim, 1995).
Homelessness is perpetuated by a culmination of relatively ‘minor’ setbacks that reinforce an
individuals’ need to ‘just’ survive not allowing them to ever get ahead (Clarke, Williams,
Percy, & Kim, 1995). Socially we need to support these people and implement a system that
facilitates real change rather than ad-hoc or short-term temporary fixes.
Contributing research interventions presently identified in the literature include
psychosocial assessments to determine individual needs, outreach teams to address barriers to
care compliance, reducing barriers faced by homeless patients, utilizing outpatient referral
resources, improved continuity of care, and involving the community. Conducting a needs
assessment is important within micro level interventions as it will inform subsequent
intervention and supports the value of meeting each person where they are and not
compromising that interaction by trying to pull them out of their context and imposing
dominant ideas of what is best (Kutza & Keigher, 1991). Outreach teams can also reduce

16. Pinkerton: Improved Patient Outcomes
16
barriers faced by homeless patients’ as it relates to transportation needs or forcing them to
prioritize preventative care and meeting their basic needs for survival (McDougal-Treacy,
2014). Sanabria (2006) discusses how lack of coordination can make subsequent
interventions ineffective. Rosenfield (1991) also discusses ongoing contact and continuity of
care positively impacting patient outcomes by reducing utilization of the emergency room for
non-emergencies. Parker and Dykema (2013) found in their research that providers who
practiced active referrals to outpatient sources saw better outcomes, for example reduced
emergency room visits, than providers who discharged patients with directions along the idea
of ‘If symptoms get worse come back.’. For those who are homeless they face social barriers
that perpetuate marginalization and make it more difficult to improve their situation (Laakso,
2013). Martin (2014) suggests that service providers can better serve this population by
reducing burnout among providers so they can provide a good experience to service
recipients that encourages them to seek help, reducing material barriers or help people
overcome material barriers such as requirement of identification or a mailing address, value
individuals’ need for self-efficacy and self-esteem, and build human relationships that reduce
the separation of patient and professional. Assertive Community Treatment (ACT) teams are
another possible intervention that was mentioned in the literature as possibly effective
intervention. ACT teams have been found to reduce the negative impact of staff turnover,
thus supporting continuity of care, and may address the challenges associated with care non-
compliance as a result of choice or addressing barriers to full participation (Bond, et al.,
1991; Rowe, Kloos, Chinman, Davidson, & Cross, 2001). ACT teams work from a strengths
based perspective, address patient identified needs, and provide a stable foundation for
ongoing treatment (Rowe, Kloos, Chinman, Davidson, & Cross, 2001). Dubose (2014) was
able to share information related to the Ambulatory Care Coordination Team (ACCT)
implemented by Multicare that is similar to ACT teams and has potential applications beyond
the population it is currently serving. The ACCT currently serves patients who are high
utilizers of inpatient services, through referrals from Multicare Staff, by providing
intervention to improve self-management and improve health outcomes. This team could be
expanded to intervene in the ED prior to inpatient hospitalizations and could expand meet the
needs of our homeless patients who are high utilizers by helping them connect to services
and support follow-up with their care providers.

17. Pinkerton: Improved Patient Outcomes
17
After consideration of the current research and discussions with key informants, there
is a gap in the current hospital setting as it relates to effectively meeting the needs of our
homeless patients who are high-utilizers of the ED. Having a designated role or staff to
develop and maintain MOUs that facilitate prevention, crisis intervention, and continuity of
care would be a valuable additional to our intervention strategies. Socially, and as an agency,
we are falling behind in addressing the needs of this vulnerable population and it would be in
our best interest to take the time now to implement effective solutions rather than waiting
until the problem reaches a crisis level that becomes subjected to additional mandates from
external entities and public policies. The research indicates a need for better interpersonal,
interdepartmental, and interagency collaboration to do more to increase efficacy of initial
interventions and improved preventative measures to reduce unnecessary readmissions.
Risk/Priorities
By implementing this proposal our agency will benefit from financial savings,
possible future funding opportunities, better patient outcomes, and improved connectedness
with the community. There is no denying that the funding structure for healthcare is
changing. Policy makers and funders are shifting towards outcome based compensation and
we have an opportunity to implement interventions now that will better position our agency
to maintain funding streams in the future. This intervention mandates maintenance of
community partnerships that will serve our agency better as we can utilize one another’s
resources in order to most effectively meet the needs of our patients rather than having the
patients overly rely on an emergency system that can only defer to community providers
nonetheless. In addition to more effectively using resources that currently exist in the
community we also build social capital with our partners and key stake holders who will
have a vested interest in the success of our facility.
This intervention is highly feasible as it draws from roles and programs that already
exist within our agency. Our Social Workers, Care Managers, and ACCT all have
components of the proposed intervention but no single role has been able to effectively meet
the need of this vulnerable patient population. Potential barriers include navigating the
boundaries between this proposal and the current system as well as identifying the extent of
the need and how this position will most effectively serve our multiple locations. This project
will most effectively be implemented as a pilot project that initially focuses on establishing

18. Pinkerton: Improved Patient Outcomes
18
MOU’s and developing the resource database then gradually starts accepting referrals to
begin the proposed intervention. Potential liabilities include those incurred by having staff
working in the field rather than strictly within the hospital, providing transportation to
patients in private vehicles, and making sure that the intervention does not supplant resources
available through community partners or appropriate hospital staff.
Political interest in the homeless population and what kind of services should be
available to them has varied over time. Despite heightened public awareness of homelessness
as a social problem we still see the general public and policy makers acting on ideas that
people in poverty are there as a result of their individual characteristics without consideration
of the systemic or cultural context within which they became homeless (Laakso, 2013).
Within the ED, patients who are homeless may be treated differently regardless of whether
their presenting problem is shelter-seeking, a result of complications of drug abuse, active
psychotic symptoms, or a legitimate medical emergency; this variance is an example of our
cultural attitudes where the quality of care that is delivered depends on whether you are
deemed worthy to receive it. Although there is still social bias related to the issue of
homelessness it is still omnipresent throughout political conversations from the local through
the Federal levels of government. Through the current discourse we have an opportunity to
effect change and participate in the conversation while meeting the needs of our patients and
our agency.
Within our agency there will be limited policy changes as we define the role and
scope of this intervention and incorporate it into the current structure. We will need to
consider the system as it presently exists and may need to negotiate aspects that overlap with
current departments or roles.

19. Pinkerton: Improved Patient Outcomes
19
Bibliography
Applebee, K. (2014, December 1). Assistant Nurse Manager- Emergency Services. (J. Pinkerton,
Interviewer) Auburn, Washington.
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20. Pinkerton: Improved Patient Outcomes
20
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Univeritas Psychologica, 5(1), 51-67.

21. Pinkerton: Improved Patient Outcomes
21
Homeless people’s needs are met
No improvement of problem intensity
Elimination of the problem
RestrainingForcesDrivingForces
Federal Mandate-
MnKinney Vento Act
Increased public
awareness of causes
of homelessness
Local efforts to create safe
spaces (ie Safe Parking Program
in Seattle, encampments on
private property)
Affordable
Healthcare
211 information center
to locate food banks
and other services or
essential needs
Programs focused on
community stabilization as a
preventative or transition
service
Increased accessibility of
information through internet
search and interagency
collaboration
Programs that
provide community
voicemail or free
phones
Daytime services to
meet hygiene needs Vocational
rehab services
Funding priorities depend
on trending issues
A practice of “other-ing”
or society not wanting to
acknowledge problem
Communities pushing out
undesirable set-ups (ie tent
cities, low barrier housing,
shelters, methadone clinics)
Lack of funding for
alternative housing
options
Providers not wanting to
be reimbursed at lower
rates (Medicaid patients
or Section 8 tenants)
Unstable employment
Barriers to getting
needing
identification to
obtain services
Programs favoring
“certain types of
homelessness” ie families,
people with cars,people
who can speak English
Migration of individuals
following available
resources
Instability of access
to available resources
(like transportation
needs)
Problem Map

22. Pinkerton: Improved Patient Outcomes
22
Homeless overutilization of the ED for non-emergencies
Inadequate system response to homelessness
Gaps in service continuum
(housing, healthcare,mental health
treatment, education, employment
support, etc.)
Funding issues/ inadequate funding
“We do enough for them”
Homeless people have
nowhere else to go
Existing services are exhausted
Not a funding priority because “they
made their bed they can lay in it”
Involuntary Admit
Private behaviors acted out in a public space
Limits on utility of public space
Civil detention expectations for individuals
who violate social expectations of appropriate
use of public space
“Not in my backyard”
“Keep them out of sight
“
Voluntary admit
Socialized to
seek care of ED
Lack of alternative
resources
Providers not willing to
take new patients that
can be billed/reimbursed
at a lower rate
Person(s) left without
medications, food, shelter,
other basic necessities
Person(s) feeling without
hope or devalued
Person(s) may engage in
maladaptive coping
Desperation
Learn what to say to survive; exhibit
problem behaviors, make false
claims; play into socially expected
behavior (“act crazy” state SI/HI)
Get to stay, basic needs met
Reinforcement of ED Utilization
Loss of individual choice until deemed safe to go
If deemed unsafe
then referred to
involuntary psych
placement
If detained possible
loss of citizenship
rights
Less self-esteem and
les self-determination
Less motivation to be productive
Resentful or antisocial
“I need/
seek help”
Recognized
need exists
I’m of no
value” “I’m
angry”
Force Field Analysis