Socially marginalized groups, including homeless individuals, have historically experienced significant barriers and fragmented access to needed healthcare services. This situation is particularly problematic, given the disproportionately high burden of both acute and chronic conditions. Despite increased rates of illness and mortality, most homeless individuals are less likely to have a regular source of primary care than the general population. The Affordable Care Act has expanded coverage to several previously uninsured individuals, such as homeless-experienced individuals, drastically shifting the healthcare delivery context. The implementation of the Affordable Care Act has made obtainable services and supplies once previously unavailable to the uninsured homeless population. However, the impact of the Affordable Care Act on the growing homeless population in the United States remains under-examined, from the participant perspective.
Purpose
The purpose of this study is to explore the perceived facilitators and/or barriers to having a regular source of primary care services among homeless-experienced individuals within the post-ACA United States within a state that has adopted the Medicaid expansion.
Methods
Study Design: This qualitative study employed a directive qualitative content analysis approach. Relevant research was used as a guide for the development of initial codes (Graneheim & Lundman, 2004; Hsieh & Shannon, 2005; Priest, Roberts & Woods, 2002). The University of California, San Diego Brief Assessment of Capacity to Consent (UBACC) Instrument was used to assess decisional capacity to consent.
Participants: This study took place at an integrated health service clinic that primarily serves homeless individuals in Chicago, Illinois, USA. The study population involved utilizers of an urban clinic that provides integrated primary, oral, and behavioral healthcare to homeless participants. The urban integrated health service clinic has three primary care sites, with several community outreach sites. The sampling frame involved utilizers of the one integrated health service clinic site. To be eligible for inclusion, all individuals had to be a participant at the urban integrated health service clinic where the study was taking place; ≥ 18 years of age; able to communicate in English language; and able to demonstrate decisional capacity to consent.
Data Collection: Interviews were conducted with homeless-experienced participants from November – December, 2017 by the principal investigator (KD). The study purpose and aims were explained to each participant by the primary investigator. All twenty participants completed the University of California, San Diego Brief Assessment of Capacity to Consent, achieving a passing score of at least 15. Participants were informed that all semi-structured interviews would be audio-recorded; the principal investigator began the interview with question one of the interview script and followed-up with probing questions, posing all five questions to each of the 20 participants.
Data Analysis: The principal investigator (KD) transcribed interview audio-recordings, reviewed transcripts for accuracy, and identified key themes. A directive qualitative content analysis approach was employed. The principal investigator (KD) consulted with the second and third investigators (SB, DI) to convey the established coding scheme and to ensure inter-coder agreement. Discrepancies regarding coding scheme and conceptual definitions were negotiated and resolved within the triad. The principal investigator (KD) independently applied the final coding scheme to the entirety of qualitative data. The final coding scheme was then utilized by the third investigator (DI), who independently coded a random sample of 25% of the data (5 interview transcripts); code-recode agreement was then verified by the first investigator (KD), who re-coded 25% of the data (5 interview transcripts). Data were analyzed using the Dedoose qualitative cross-platform application (Dedoose, 2018).
Results
65% of participants identified as male, 35% of participants identified as female. The majority (70%) of participants identified as African American/Black, 25% identified as Caucasian/White, 5% identified as Latino/Hispanic, and 5% identified as Middle Eastern. Eighteen of the twenty participants (90%) reported being enrolled in Medicaid, or having a medical card; two of the twenty participants (10%) reported being without medical insurance or other documentation. Nineteen (95%) of participants reported having utilized the site of primary care at least one time prior, with several participants reporting having come to the site for multiple years. In exploring the contributors and deterrents of utilizing a regular source of primary care among homeless-experienced individuals, themes clustered around promoting and inhibiting factors. That is, participants detailed their experiences of individuals and systems that either facilitated or served as barriers to their returning comfortably to a regular source of primary care. Nine themes emerged from the data (5 facilitators, 4 barriers). Facilitators of having a regular source of primary care included experiencing: (a) a sense of community, (b) mutual participant-provider respect, (c) financial assurance, (d) integrated health services, and (e) participant care teams. Barriers to having a regular source of primary care included experiencing: (a) feeling unwelcome or misunderstood, (b) feeling judged and disrespected, (c) a lack of health insurance, and (d) receiving care from multiple care sites.
Discussion
For myriad reasons, barriers to necessary primary care for homeless individuals persist. While the perpetuation of this issue is clearly demonstrated in the literature, the participants in this study represent a sub-sample of the homeless-experienced population that accesses and uses a regular source of primary care. Their voices offer insight into how researchers, clinicians, and policy-makers can address the issues that have allowed decades of disproportionate unmet need, morbidity, and mortality.
Conclusion
To promote equity in access and outcomes, understanding the factors that both promote and prevent access to and use of a regular source of care among homeless-experienced individuals is pivotal. Promoting the systematic presence of facilitators, such as the cultivation of a sense of community, mutual participant-provider respect, financial assurance, availability of integrated health services, and patient care teams can ensure appropriate access to and utilization of primary care services from a regular source of care. Also towards this end, working to minimize barriers by creating welcoming and understanding healthcare contexts and personnel, providing education to decrease attitudes of judgment and disrespect, ensuring access to health insurance enrollment, and eliminating the need to travel to multiple sites for care may also help achieve greater uptake of regular primary care services. Through recognizing and developing strategies to actualize facilitators and minimize barriers to care, the healthcare needs of homeless populations may be more effectively addressed.
See more of: Invited Posters