A Multiple Stakeholder Case Study: Implementation of a High Intesity Community Health Worker Program in Primary Care Settings Serving Homeless Adults

Background and Purpose: Emergency room admissions rates related to non-urgent or preventable admissions are one of the highest for homeless persons, representing 20% of the most frequent emergency room utilizers. This pilot study examines the feasibility and acceptability of delivering Collaborative Self-Management with a high intensity community health worker (CHW) model to decrease emergency room service use patterns among homeless adults managing chronic health and mental health co-morbidities.  The intervention aims to improve care coordination and health outcomes for a population that is recognized to incur high healthcare costs.  Perceptions of factors that promote and inhibit the implementation of the Collaborative Self-Management intervention with chronically ill homeless adults in a community-based care setting are explored. Methods: A purposive sample of participants representing various stakeholders that included consumers, direct care providers, administrators, and physicians were recruited (n=6).  In-depth semi-structured qualitative interviews in conjunction with a focus group were conducted.  Narratives were analyzed using the constant comparative method informed by grounded theory.  Results:  Emerging themes were organized representing facilitators, barriers, and requirements for successful implementation framed by the Model for Collaborative Care Sustainability.  Facilitators included communication among providers at all agency levels to allow for incremental adaptation of the recruitment and intervention protocol to manage the transient nature of the homeless patient population. Recommended adaptations were around street outreach approaches for follow-up and booster sessions.  Team based care approaches with the physicians and CHW’s were also noted as central to the program success with CHW’s working as medical translators and assisting with patient navigation.  Primary barriers included adhering to project data collection efforts and financial resources to sustain the program costs.  Requirements for the project effectiveness included streamlined outcomes tracking on all data collected. There was also an emphasis on the need to successfully and continually address non-health needs that include mental health care, combating distrust of agencies and health care professionals, and establishing access to basic resources (stable shelter, food and prescribed medications). Conclusions and Implications: Findings indicate that an adaptive and open communication environment is central to successful implementation of the Collaborative Self-Management approach with homeless adult populations. A key factor to this success is strong coordinated care with attention to the acute health, mental health and social service needs of chronically ill homeless adults with the CHW as a central component to that work. Approaches to increase the translation of evidenced based care models in meeting the needs of hard to reach and high need populations within community based care settings are discussed.