By Traci Haynes
Homelessness in America occurs in every state and has many causes. According to the January 2017 Point-in-Time (PIT) count by the National Alliance to End Homelessness, the most recent national estimate of homelessness in the United States identified 553,742 people experiencing homelessness. The PIT count is a count of sheltered and unsheltered homeless persons on a single night in January. Like all surveys, the PIT count has limitations. Results are influenced by the weather, availability of overflow shelter beds, the quality of the volunteers, and the level of engagement of the people being interviewed.
Most of this population lives in some form of shelter or transitional housing. However, approximately 35 percent live in places not meant for human habitation. The nature of homelessness makes it difficult to quantify the true size of the homeless population, not to mention the PIT methodology (although generally acknowledged to be the most accurate way to establish valid trend data). It is challenging to calculate the exact number of individuals who are homeless, because many live in hidden areas in parks, vehicles, or abandoned houses, and because numbers fluctuate based on weather.
Health Problems Faced by the Homeless
Homeless individuals are at a relatively high risk for a range of acute and chronic physical and mental illnesses. Some health problems precede and may contribute to homelessness, while others are often a consequence of being homeless. And homelessness complicates the treatment of many illnesses.
One example of a health problem that can cause homelessness is a major mental illness, such as schizophrenia. Without therapeutic interventions and supportive housing arrangements, such an individual may become homeless.
Another example is an accidental injury, including job-related injuries. Even with benefits under employer programs, these individuals may experience major economic costs leading to loss of housing.
Diseases of the extremities, skin disorders, malnutrition, degenerative joint diseases, dental and periodontal disease, communicable diseases, and the possibility of trauma are other health problems that may result from, or frequently occur in, the homeless population. Medical care and treatment for acute or chronic illness can be extremely difficult.
Bed rest may be nonexistent for a homeless individual who has no bed or only has a bed in a shelter at night. Special diets and medication adherence are impossible to maintain for a person who is homeless.
Contact centers have long been known for assisting their organizations in offering triage, coaching, remote patient monitoring, and care management for an identified population. Some contact centers have also assisted other community agencies or services in filling a need or gap.
Triage Call Centers Can Help Address Health Concerns of the Homeless
So, we all know homelessness exists, and it is a tremendous problem, but what does that have to do with triage call centers?
A community triage contact center at EvergreenHealth in Kirkland, Washington, implemented a program around 2000, in which they began to offer low-level acuity triage for their regional 911 dispatch centers. The dispatchers would go through their algorithms with the caller, and once they ruled out any emergent or urgent issue, the caller was offered the option of speaking with a nurse. If the caller preferred, she or he could be connected with an appropriate unit or the individual could be transported to the Emergency Department (ED). This program proved a tremendous success in both caller/patient satisfaction and dollars saved.
A study was published in 2015 for a comparable 911 program in two cities with similar outcomes. MedStar in Fort Worth, Texas, provided nine months of 911 call data, and LMEMS in Louisville, Kentucky, provided thirty-four months of 911 data. The study reported that the 911 program had a significant reduction in callers routed to the Emergency Department (ED) at a cost savings of 1.2 million dollars in payments, as well as a decrease in emergency ambulance transports resulting in a cost savings of $450,000 and a resultant increase in access to alternative care. Overall, patient satisfaction was 91.2 percent.
As a result of the involvement with the regional 911 dispatch centers, the contact center was asked to become involved with yet another identified need: the growing population of homeless individuals. County shelters and housing facilities for the homeless population needed a resource for individuals with low to moderate acuity symptoms, when medical or nursing personnel were not on-site. The fire department was handling 90,000 incidents per year, which resulted in overuse or misuse of the emergency medical response (EMR) system. And while the county shelters were not most of the calls, they were a contributor.
Addressing the Concerns of the Homeless
A critical concern to the homeless individual is whether they will lose their shelter bed for the night if they are transported. The fire department is not authorized to make a medical diagnosis on the scene, to provide advice or guidance about disease management, to make a referral to other medical resources, such as a primary care doctor, or to provide transportation anywhere except an ED.
The contact center had the system and tools in place to assist the RN with the individual at the county shelter’s assessment and make recommendations of care. “Right care, right place, right time” is the fundamental premise of contact center RN triage. Their service provided a much-needed solution to an ongoing gap in care. They currently support five dispatch centers in providing contact center RN triage for thirteen shelters.
The contact center educated the staff at the shelters and facilities. They provided training on when to call 911 (a red flag list) and when to call the contact center’s health line. Each homeless individual received HIPAA information that included “understanding and agreement that a copy of the information discussed during the call interaction would be shared with the residence so that they may further assist the individual with their care.”
The workflow included one number for all facilities to dial into the Healthline contact center. The case manager and the resident had to be available at the time of the call. The RN in the contact center triaged the individual, and then the case manager determined the best non-EMR transportation based on the disposition. The triage note was then faxed to that facility.
Challenges included the individual wishing to remain anonymous, the individual being a vague or poor historian, individuals declining triage or the recommendation, availability of OTC meds, and individual psych/social needs.
Eighteen months after the start of the program, the facility staff was queried, and all were either very or somewhat comfortable in knowing what situations required 911. Over 85 percent of the staff felt the service was especially important to the facility.
By far, the majority felt that the nurses at Healthline were very knowledgeable (83.33 percent). More than 85 percent also felt that the nurse line process was easy to use and felt that the residents were satisfied with the service. Most of the staff felt very satisfied once the resident had talked with the nurse, and 100 percent indicated the importance of having the service available 24/7, adding that it was practical and helpful to the residents in the facility.
Traci Haynes MSN, RN, BA, CEN, CCCTM, is the director of clinical services at LVM Systems, Inc., and has been involved in the contact center industry for over twenty-five years. (Traci thanks Cheryl Patterson, BSN, RNC—TNP, clinical manager—quality and education, Healthline, for her contributions to this article.)