U.S. Department of Veterans Affairs, Department of Medicine at the Cpl. Michael Crescenz VA Medical Center, Philadelphia, PA, USA.
U.S. Department of Veterans Affairs, Center for Health Equity Research and Promotion, Philadelphia, PA, USA.
J Gen Intern Med. 2019 Jul;34(7):1213-1219. doi: 10.1007/s11606-019-04895-x. Epub 2019 Apr 16.
The Veterans Health Administration (VHA) has a long history of addressing social determinants of health, including housing. In 2012, the VA integrated a two-question Homelessness Screening Clinical Reminder (HSCR) into the electronic medical record in outpatient clinics to identify Veterans experiencing housing instability and ensure referral to appropriate services.
This study explores perspectives of VA clinical providers regarding administration of the HSCR, their role in addressing housing status, and how a patient's housing status impacts clinical decision-making.
We conducted a qualitative study using in-depth semi-structured interviewing.
Twenty-two providers were interviewed (20 physicians and two nurse practitioners) between March and September 2016.
Interviews were conducted with Veterans Health Administration (VHA) physician and non-physician practitioners who had administered the HSCR and documented at least five positive screens between 2013 and 2015. Our interview guide investigated provider experiences with administering the HSCR and addressing affirmative responses. The guide also elicited details about how patients' housing instability was identified (if at all) prior to implementation of the screening reminder, and how practices changed following implementation of the HSCR. Transcripts were analyzed using a modified grounded theory approach.
Providers reported that the HSCR prompted them to incorporate patient housing status into routine assessment, which they typically did not do prior to its implementation. Providers discussed adverse impacts of housing instability on patients' overall health and described how they factored patients' housing instability into clinical decision-making. Although providers viewed the health system as having an important role in addressing housing concerns, there were mixed opinions on whether it was the role of providers to directly administer the screening.
Integration of a screener for housing instability into the electronic medical record increased provider attention to housing instability into the social history, and positive responses commonly impacted plans of care.
退伍军人健康管理局（VHA）长期以来一直致力于解决健康的社会决定因素，包括住房问题。2012 年，VA 将一个包含两个问题的无家可归筛查临床提示（HSCR）整合到门诊电子病历中，以识别住房不稳定的退伍军人，并确保将其转介给适当的服务。
本研究探讨了 VA 临床医生对 HSCR 的管理、他们在解决住房状况方面的作用以及患者的住房状况如何影响临床决策的看法。
我们采用了定性研究方法，使用深入的半结构化访谈。
2016 年 3 月至 9 月期间，共对 22 名提供者进行了访谈（20 名医生和 2 名护士从业者）。
访谈对象为退伍军人健康管理局（VHA）医生和非医生从业者，他们曾管理过 HSCR，并在 2013 年至 2015 年期间记录了至少五个阳性筛查结果。我们的访谈指南调查了提供者在管理 HSCR 和处理肯定回应方面的经验。指南还详细了解了在实施筛查提示之前，如何确定患者的住房不稳定（如果有的话），以及在实施 HSCR 后，实践如何发生变化。使用修改后的扎根理论方法对转录本进行分析。
提供者报告称，HSCR 促使他们将患者的住房状况纳入常规评估中，而在实施之前，他们通常不会这样做。提供者讨论了住房不稳定对患者整体健康的不利影响，并描述了他们如何将患者的住房不稳定纳入临床决策。尽管提供者认为卫生系统在解决住房问题方面发挥着重要作用，但对于提供者是否应该直接管理筛查，存在着不同的看法。
将住房不稳定筛查器整合到电子病历中，增加了提供者对社会历史中住房不稳定的关注，阳性反应通常会影响护理计划。
