Background: The care management and discharge planning of psychiatric patients experiencing homelessness (PPEH) is an area of debate. Due to the lack of research on best practices and community resources available, there are currently insufficient actionable guidelines in place to properly assist PPEH in their psychiatric care post-discharge, leading to high rates of readmission. Though PPEH would greatly benefit from community placement in supportive long-term care facilities, gaps in funding and resources have led to long waitlists and early discharges from psychiatric wards without proper placement. Corollary to this, other patients are forced to board for longer than medically necessary in inpatient settings while awaiting an appropriate community placement. Longer inpatient stays are often discouraged as they are likely to lead to revenue loss and cause psychological damage to the patient. Though psychiatrists may request that the patient is added to a placement waitlist, once the patient has been discharged, they are dropped lower on the waitlist. Without access to an appropriate level of care post-discharge, PPEH often decompensate, leading to higher rates of readmission. There is currently very little research qualifying or quantifying how homelessness impacts psychiatric care and discharge planning. Without data analyzing the gaps in care experienced by PPEH at discharge, it is hard to support legislation or policy changes designed to improve individual and systems-level outcomes.
Methods: One-to-one semi-structured interviews were conducted with self-identified PPEH in the state of RI. Transcribed interviews were analyzed in NVivo using the framework analysis method known as immersion-crystallization. Prior to the first read of the transcripts, the author generated a list of initial a priori and empirical codes based on the interview guide and memos. Once the author completed this first read, they compiled the new empirical codes from each transcript and conducted a second read, additionally coding all transcripts for each of these. The author then organized all codes into a taxonomy, grouping them by successively broader themes. Quantitative data were analyzed using appropriate statistical tests.
Results: Approximately 60% of PPEH reported that they had not been screened for homelessness. Of the 30% of PPEH that had been screened, 76% perceived no modification in their discharge planning. Whether or not a PPEH was screened for homelessness significantly impacted their number of hospitalizations (p< 0.0001), but did not impact their perceived confidence or ability to follow their discharge plan. Immersion-crystallization revealed two major themes discussed by PPEH when questioned about areas in need for improvement at discharge: patient-centered approaches and increasing access of resources.
Conclusions: A large percentage of PPEH are not screened for homelessness prior to discharge from in-patient psychiatric care leading to higher rates of hospitalizations. Of the patients that are screened, most did not perceive any subsequent change in their discharge planning. These data strongly suggest the need for physician training to improve structural competence and for the creation of in-patient discharge guidelines that screen for homelessness or barriers while providing a patient-centered discharge plan. This may include empowering physicians to utilize or connect the patient with a third party such as an in-patient PPEH social worker unit or reviewing resources available to patient.