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Health Promotion Final Paper: Homeless in Wilmington

Jason Keller

RN to BSN Nursing Program, Delaware Technical Community College

NUR 330: Population and Community Health

Dr. Karen Wagamon

April 9, 2023
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Health Promotion Final Paper: Homeless in Wilmington

Homelessness should never be fathomable to anyone considering the advancements in

almost every industry and aspect of the United States since its inception. Still, many Americans

to this day live in fear of becoming homeless or worse have made the transition to living on the

streets. Though Delaware has many opportunities available to live a prosperous life, we continue

to struggle with homelessness, especially in the small city of Wilmington. Many factors can lead

to the unfortunate circumstance of becoming homeless. Whether it would be financial hardship

(lack of affordable housing, unemployment, and poverty), substance abuse, or disabilities,

homelessness is becoming a greater issue than once perceived as the issue brings many problems

and concerns, and requires specific needs and solutions to rectify the problem.

Many of the problems homeless people experience daily, other than housing, are

problems that contribute to making their health worse. Needing to consume enough food

(especially fresh and nutritious foods) is typically the first problem that comes to mind.

“Inadequate nourishment directly results in innumerable physical, mental, and emotional health

consequences that lead to heavy cost burdens, further health concerns, and even death” (National

Coalition for the Homeless, 2022). Having the ability to pay for and store the food is some of the

main concerns. On a broader epidemiological scale, the homeless face several health concerns

which are exacerbated due to their situation. One of these major diseases is tuberculosis (TB). In

the United States, TB incidences have declined to less than three per 100,000 but the homeless

are more susceptible to the disease. “The increased risk of infection with TB germs is due to

several factors, including substance use, HIV infection, and the homeless shelter environment

such as crowding and the state of the ventilation system” (CDC, 2023). With Delaware being a

small state, we are fortunate to have low incidences of TB within our population. According to
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an article in the Delaware Journal of Public Health, “Delaware had 15 active TB cases in 2017, a

case rate of 1.5 cases for every 100,000 people, well below the national average of 2.8” (Suder,

2019). Within the past several years, this has increased to 4.1 within 2021 as 2022 data has not

been released yet. Other epidemiological health issues within the population are HIV, alcohol

and drug abuse, mental illness, and many other chronic diseases and conditions that plague this

community. Interestingly, even age-related conditions appear far earlier in homeless people

compared to normal healthy individuals. This includes cognitive impairments, declination in the

ability to perform activities of daily living, to even incontinence.

Review of the Data

Delaware has a longstanding issue of homelessness. In the 1800s, the poorhouse existed

for those who are and have become homeless. It was known as the “crazy house” in which there

were no rules or regulations regarding the care for the residents. It was common to hear about

issues in which neglect, abuse, and suffering were day-to-day occurrences. It wasn’t until the

mid-1900s that more facilities were opened up and more regulated. As time rolled on,

homelessness rates were exploding due to the drug epidemic and economic struggles. “Point

estimates of the number of sheltered homeless persons on specific dates in 1986 and 1995 reveal

that the state's sheltered population grew by 146 percent over this nine-year period” (Peuquet,

1996). Recently, the 2020 Annual Homeless Assessment Report, “twelve in every ten-thousand

people were experiencing homelessness” and estimates reveal that Delaware has approximately

1165 within the state. Due to the COVID-19 pandemic, this number is a significant increase

compared to previous years. “Public school data reported to the U.S. Department of Education

during the 2018-2019 school year shows that an estimated 3,547 public school students

experienced homelessness over the course of the year. Of that total, 20 students were
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unsheltered, 203 were in shelters, 577 were in hotels/motels, and 2,747 were doubled up”

(USICH, 2020). It’s easy to see that homelessness isn’t resolving itself anytime soon with this

population. At this rate, should another pandemic or economic crisis happen, the homeless issue

will continue to rise exponentially.

Disparities and Barriers

The homeless population faces many disparities and barriers to everyday life and proper

health care is no exception. As discussed earlier, the homeless face health issues far severely

more than Americans with homes. Often, barriers to medical attention include a lack of

knowledge of where to seek care, lack of transportation, and even a lack of proper identification

have been known to cause a lack of treatment. Many homeless who are ill don’t seek medical

care or seek it when it’s life-threatening due to the burden of costs associated with the care.

Lack of insurance or not being able to afford care results in the use of an emergency

department at a local hospital where anyone must be treated due to policies and laws in place.

Within the emergency departments in the local hospitals, treating people who are homeless is an

everyday occurrence. The unfortunate side of it is that those who are seeking treatment, they

waited until the conditions are life-threatening. Many times, the length and frequency of hospital

stays are increased due to the deconditioned nature they’re in. “ED utilization by homeless

patients is three times the US norm and has increased 80% over the last 10 years. Homeless

patients are more likely to be “frequent users” (≥4 visits/yr) or “super users” (≥20 visits/yr) of

the ED, and thus utilize more resources” (Franco, et al, 2021). This has a rippling effect on the

overall effectiveness of healthcare as well as the need for many additional resources to help

lessen the frequency of visits by this population.

Tackling the issues of barriers alone can be challenging. One recommendation for

affording the cost of health care, which already is in place in Wilmington, is to allow the

homeless to stand along the streets asking for money/help. Wilmington does restrict the time of

day in which a person can panhandle thus reducing traffic incidents as well as other potential

issues. Lack of transportation is another barrier that can use some updating to modern times.

Companies that employ contractors to use their cars for transportation can come up with a

solution for transporting the homeless population to healthcare appointments. People who do this

work would then receive compensation through the company or a favorable tax benefit. Lack of

health insurance was another large issue at hand which received a refresh due to the Affordable

Care Act. Through this drastic change of policy, many now have health coverage for the first

time. “Millions of people who earn less than 138% of the federal poverty level and are fortunate

enough to live in “expansion” states are being enrolled into Medicaid” (Substance Abuse and

Mental Health Services Administration, 2020). This granted many people improved access to

health services and receive even higher quality of care. “It shifts the focus of health care delivery

on outcomes and value — not procedures and volume — putting “whole person” health at the

forefront and encouraging partnerships between health care and other needs like housing and

social services” (United States Interagency Council on Homelessness, 2014). Not only did the

impact have a positive impact on the homeless though. Healthcare providers throughout the

country have better access to resources which significantly reduced the need for emergent care

and hospital services. This was an extraordinary start to helping the homeless with access to

health care. Though it had its downsides, the Affordable Care Act can be further tweaked as

many lessons were learned but we can continue to help the homeless population with their access

to proper medical needs.

SMART Goals

SMART Goal #1: Establish Homeless Triage Clinic Next to Emergency Departments

SMART Goal #2: Continuous Monitoring of Homeless Shelter Operations

SMART Goal #3: Expand Employment Opportunities

Role of the Nurse

As quoted in our textbook, “hospitals will continue to downsize as hospitals will move

out into the community” (Savage, 2020). This means that we will need a significant move

outside of the hospitals soon to manage the health conditions of all populations. This can’t be

truer in a sense of having to manage the health effects of becoming homeless can have. Nurses

are crucial in developing and diving into various roles to help this population. On a broad and

general outlook on the roles one can have when addressing the homeless population, nurses can

provide primary care in clinics and health education within and outside those clinics which aid in

preventing the spread of disease within the population. These roles improve the access to

healthcare for this population who don’t have the resources and capability to seek help. With the

SMART goal of establishing homeless triage clinics next to emergency departments, nurses can

work in these specific triage areas to provide all kinds of direct care to this population. This not

only reduces the overall load on the emergency departments itself but could prevent long hospital

admissions for simple care.

A nurse can also work in homeless shelters to provide the same quality of care. For

example, a nurse can offer a small clinic to check for frostbite if it’s in a region known for

having harsh winters. A nurse can be the direct advocate for the homeless which links up

treatment facilities to get the necessary care. A nurse can also be responsible for the overall

monitoring of operations of these shelters as stated in the second SMART goal. Simply being an
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advocate for the homeless population can establish a dramatic change in the overall environment

of how the shelter is run and increase their safety for them.

In the third SMART goal, employment opportunities can offer a chance for homeless

individual to change their life. A nurse can be an advocate by connecting a homeless person to a

job fair or local training program that offers training at a low cost or is tuition free. A nurse could

also assist in establishing a relationship with job placement companies once this training is

complete. Within the legislation, nurses can fight for tax benefits to companies that employ the

homeless.

Interventions and Resources

Resource #1: Queen’s Nursing Institute

At the Queen’s Nursing Institute in the UK, an organization filled with many roles has

been created to address the growing issue. They’re called homeless health nurses. “The QNI has

supported the development of a series of projects and programmes over the past ten years,

including national conferences, learning events, unique learning resources, and a specialist health

assessment tool for nurses working with people who are homeless” (Queen’s Nursing Institute,

2018). This well-established institute can offer tremendous amounts of insight into what it takes

to be a nurse in the homeless population. They are the experts who specialize in the care of this

population so who better to help implement the skills needed to have a specific triage center at

the emergency department? As stated earlier, the long-term benefits outweigh the high short-

term costs associated with establishing these triage centers due to preventing long-term

admissions for those homeless people. There’s no need to wait till health conditions are severe

enough since most homeless only know about only being able to get medical attention at an

emergency department.
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Resource #2: Division of State Service Centers, Office of Community Services

The Division of State Service Centers, Office of Community Services is a direct resource

for the funding of private, non-profit agencies in Delaware that provide shelters for emergency

use and transitional housing for the homeless. With their partnership, there could be a well-

established program that offers continuous monitoring of homeless shelters. Although there

probably are criteria already in place to be able to provide funding, there could be areas that can

be expanded for improvement. Alternatively, we could also implement a program that goes

above and beyond the bare minimum of just qualifying for funding. The program could benefit

these shelters by even improving the shelter's functions and providing safer places to live while

in either emergencies or transition.

Resources #3: Projects in Transition from Homelessness

Projects for Assistance in Transition from Homelessness or PATH is a federally funded

program is to provides services and assists with treatment and support. This resource could be

used to provide opportunities for the homeless in transition to get a job. The organization already

offers job training so this part of the program could be expanded. Many jobs can be created

through federally funded programs to help the homeless earn a living income to further support

the transition. Having a job can create the feeling of being responsible again for one’s own life.

In turn, that person will be motivated enough to never go back to living on the streets again.

Health Promotion Plan

SMART Goal #1 Interventions:

Many interventions can be included within the first SMART goal of establishing a triage

for the homeless. Case management is a large intervention. Since the goal is to minimize hospital

admissions or shorten stays, having a case manager involved is needed to see that the person is
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getting treated adequately and able to be discharged promptly. Health teaching is another

intervention. Education is important to the patient. This offers potential preventative measures in

the future to treat accordingly thus reducing longer admissions. Advocacy is another large

intervention. The homeless are still people and they need to be treated equally with equal access

to medical treatments regardless of ability to pay.

SMART Goal #2 Interventions:

The interventions that come to mind for the expanded monitoring of homeless shelters

are consultation and collaboration. Consultation is the most important of the three as this seeks

information and generates solutions to problems in the shelters that can be occurring. The

solutions would then be selected and implemented. Collaboration is key to any intervention.

Collaborating with other organizations and professionals can be optimal in achieving the

common goal. Within these interventions, a significant change should be established for the

operation, maintenance, and safety of homeless shelters.

SMART Goal #3 Interventions:

Community organizations would be a key intervention for expanding employment

opportunities. There could be many opportunities at local businesses and government-owned

properties for a homeless person without the skills and training to have a job. Another

intervention, like the second goal, is collaboration. Local businesses can collaborate with

government offices to establish a network of homeless workers. Then, these businesses would

get tax benefits for employing the homeless. This also can provide the opportunity for the

homeless to obtain health benefits through their employer.

Evaluation
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The hope of short timeframes to establish significant change would be ideal in a perfect

world. Establishing a new triage building for the homeless population next to an emergency

department would take a long time as this project is large. Recommendations would be in stages.

Roughly it would take a few months to plan out where to put the new triage center. If the hospital

has the space already, the triage center should be up and running and fully staffed within a year.

Should a hospital build an addition to the emergency room, this would add a significant amount

of time. Acquiring staff might take another six months with the addition of another three for

specific training led by the Queen’s Nursing Institute and their homeless health nurses. To

evaluate the effectiveness of the triage center, we would gather the data and see how many long-

term admissions of just homeless people there are compared to in the same timeframe over a few

years. A cost analysis can also be provided to see if significant savings were also achieved.

Monitoring homeless shelters would be a more feasible short-term goal. Hiring new or

promoting staff within the Office of Community Services should take no longer than two

months. Developing the tasks to effectively monitor a shelter would take another estimated six to

seven months. Overall, nine months would be enough to get the new program started. We would

use both quantitative and qualitative studies to evaluate the effectiveness of the program. Surveys

would be routinely completed and data would be collected on the safety and overall effectiveness

of the shelters.

Expanding employment opportunities is the other of the two shorter-term goals. Since

programs are ready and available already, manipulating and implementing them should take no

time to see a significant change. With the help of PATH, job training should be pushed to

comply with the program. This would provide further funding through taxes to generate more

opportunities for other homeless citizens. Evaluation would come from PATH itself.
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Quantitative data can be collected to see how many successes there are within the homeless

community. Ideally, the population estimates would start to lower over time. The timeframe to

see an impact would be no longer than a year.

Conclusion

As our population grows, more needs to be done within the community health setting. As

of right now, it seems like we’re just getting by without making significant strides to prevent

overwhelming our healthcare system. From a community perspective, the focus should be more

on prevention and management outside of the hospitals, especially with the homeless population.

With many more Delawareans on the brink of homelessness, the problem will become more

widespread across the state. We’re even starting to see significant increases in Kent and Sussex

counties of lower Delaware. Homelessness can happen to anyone at any time. Much more needs

to be done within our communities to prevent and combat the ever-growing problem.
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