Implementing a hospital-based case management intervention for people experiencing homelessness: the navigator program

Abstract

People experiencing homelessness (PEH) have worse health than the general population, and higher rates of hospitalization. The transition period after discharge from hospital is often challenging for PEH, in part due to loss to follow-up, competing priorities, housing instability, and the absence of a primary care provider. In-patient hospital stays represent a window of opportunity to intervene and connect with patients, supporting them to stay in hospital and complete their treatment plan, identify and address their social needs, and support their transition of care into the community. This qualitative study explores supports and challenges to the implementation of the Navigator Program, a hospital-based critical time intervention that supports PEH during their hospital stay and after discharge into the community.

BACKGROUND

People experiencing homelessness (PEH) have worse health than the general population, and higher rates of hospitalization. The transition period after discharge from hospital is often challenging for PEH, in part due to loss to follow-up, competing priorities, housing instability, and the absence of a primary care provider. In-patient hospital stays represent a window of opportunity to intervene and connect with patients, supporting them to stay in hospital and complete their treatment plan, identify and address their social needs, and support their transition of care into the community. This qualitative study explores supports and challenges to the implementation of the Navigator Program, a hospital-based critical time intervention that supports PEH during their hospital stay and after discharge into the community.We interviewed 35 participants (homeless outreach counsellors working on the program, hospital physicians and staff in the implementation setting, community service providers, and the implementation team) and conducted 130 h of non-participant observation. Analysis used the Framework Method and the Consolidated Framework for Implementation Research to highlight the barriers and facilitators to implementation.

METHODS

We interviewed 35 participants (homeless outreach counsellors working on the program, hospital physicians and staff in the implementation setting, community service providers, and the implementation team) and conducted 130 h of non-participant observation. Analysis used the Framework Method and the Consolidated Framework for Implementation Research to highlight the barriers and facilitators to implementation.A core aspect of successful implementation and program uptake was that all participants saw a need for the program. The flexible approach to model design and implementation was an essential approach to program development that adjusted to the implementation setting, while leaving room to create more systems and structures as the program progresses. Implementation also relied on clear approaches to attaining buy-in from all stakeholders, done through a mix of formal and informal approaches. Operating as a hospital-based program was essential for successful implementation, supporting team-building among care providers in both the healthcare and social service sectors, which can lead to improved patient care coordination.

RESULTS

A core aspect of successful implementation and program uptake was that all participants saw a need for the program. The flexible approach to model design and implementation was an essential approach to program development that adjusted to the implementation setting, while leaving room to create more systems and structures as the program progresses. Implementation also relied on clear approaches to attaining buy-in from all stakeholders, done through a mix of formal and informal approaches. Operating as a hospital-based program was essential for successful implementation, supporting team-building among care providers in both the healthcare and social service sectors, which can lead to improved patient care coordination.The implementation of programs addressing complex social and health issues can contribute to its success or failure. In this study, we discuss the effective implementation approaches of the Navigator Program, as well as lessons learned. This study provides practical and helpful strategies for implementing similar programs in hospitals across Canada, and in countries with similar healthcare system structures.

CONCLUSION

The implementation of programs addressing complex social and health issues can contribute to its success or failure. In this study, we discuss the effective implementation approaches of the Navigator Program, as well as lessons learned. This study provides practical and helpful strategies for implementing similar programs in hospitals across Canada, and in countries with similar healthcare system structures.