Abstract
Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination.Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome, to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness.Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.
Highlights
Housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population
Individuals who experience housing instability are disadvantaged due to poverty and stressors such as isolation, lack of social support, and cultural or racial exclusion [1]. These individuals have high morbidity and acute care use compared with the general population [2,3,4,5]
Guided by the United Kingdom Medical Research Council framework for evaluating complex interventions, we extend our evaluation to include an assessment of contextual factors that influence program success [39, 40]
Summary
Housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Individuals who experience housing instability are disadvantaged due to poverty and stressors such as isolation, lack of social support, and cultural or racial exclusion [1]. These individuals have high morbidity and acute care use compared with the general population [2,3,4,5]. Homelessness and poverty are significant barriers to care; often forcing individuals to prioritize food and basic needs over adherence to recommended medical care [10, 12, 13]. Stigma and discrimination in the healthcare system can cause distrust, preventing collaborative engagement and leading to acute care presentation after illness severity escalates [14,15,16]
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