Case Management, Homeless Persons, Hospital Readmission, Primary Care
Conditions
Brief summary
Individuals experiencing homelessness often have complex health and social needs. This population also faces disproportionate systemic barriers to accessing health care services and social supports, such as not having primary care providers, needing to meet other competing priorities, and difficulties affording medications. These barriers contribute to discontinuities in care, poor health outcomes, and high acute healthcare utilization after hospitalization among this population. This randomized controlled trial aims to evaluate the effect of a case management intervention (the Navigator program) for individuals experiencing homelessness who have been admitted to hospital for medical conditions. This study will examine outcomes over a 180-day period after hospital discharge, including follow-up with primary care providers, acute healthcare utilization, quality of care transitions, and overall health.
Interventions
OTHERNavigator Program
The main role of the Homeless Outreach Counsellor is to support continuity and comprehensiveness of care by helping participants follow their post-discharge plans and facilitating strong links with community-based health and social services. The Homeless Outreach Counsellor also helps address specific needs of participants, develop comprehensive care plans with members of patient's multidisciplinary circle of care, and facilitate the transition of clients to long-term community-based health and social services.
Sponsors
Unity Health Toronto
Canadian Institutes of Health Research (CIHR)
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE (Outcomes Assessor)
Masking description
Research staff who conduct 30-day follow-up interview with participant are masked to participant's assignment
Intervention model description
Intervention: specialized homeless-specific case management services starting during hospitalization and continuing for approximately 3 months after discharge. Usual care: treatment as usual, without access to specialized homeless-specific case management services.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* 18 years of age or older * Have an unplanned admission for any medical cause to the General Internal Medicine service, any Medicine subspecialty service, the Cardiac Intensive Care Unit, and the Medical Surgical Intensive Care Unit * Identified as being homeless at the time of admission or anytime during the index hospital admission. This includes patients who are: unsheltered (absolutely homeless and living on the streets or in places not intended for human habitation), emergency sheltered (staying in overnight shelters for people who are homeless, as well as shelters for those impacted by family violence), or provisionally accommodated (whose accommodation is temporary or lacks security of tenure).
Exclusion criteria
* Unable to provide informed consent to the study * Previously received services from the Homeless Outreach Counsellor within 90 days of admission
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Follow-Up with Primary Care Provider (PCP) | Within 14 Days of Discharge | Occurrence of a follow-up visit with a PCP (family physician or nurse practitioner). In-person encounters (e.g., ambulatory clinics, shelter clinics, and community health centers), virtual encounters (with video), and phone calls (without video) will be considered as follow-up visits. These modes of PCP follow-up are consistent with those outlined by quality standards from Health Quality Ontario. The investigators will ascertain PCP follow-up through: 1) participant self-report at the 30-day interview, 2) PCP office confirmation, and 3) administrative databases (OHIP and Community Health Center Databases at ICES). PCP follow-up documented in any of the three data sources will be considered sufficient to meet the primary outcome criterion. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Composite All-Cause Hospital Readmission or Mortality | Within 30, 90, and 180 Days of Discharge | Hospital readmissions will be ascertained from the 30-day interview and administrative databases at ICES. Mortality data will be collected from hospital charts, follow-up with community contacts, or administrative databases at ICES. (Hospital readmissions exclude elective or scheduled admissions, labor and delivery visits, and transfers between services \[i.e., from medicine to psychiatry\] within the hospital.) |
| Number of Emergency Department Visits | Within 30, 90, and 180 Days of Discharge | Number of emergency department visits will be ascertained from the 30-day interview and administrative databases at ICES. |
Countries
Canada
Contacts
PRINCIPAL_INVESTIGATORStephen W Hwang, MD, MPH
Unity Health Toronto
Outcome results
None listed