Question

Case study:

Married with two young children, John and his wife rented a two-bedroom apartment in a safe neighborhood with good schools. John liked his job as a delivery driver for a large foodservice distributor, where he had worked for more than four years. His goal was to become a supervisor in the next year. John’s wife was a stay-at-home mom.

John had always been healthy. Although he had health insurance through his job, he rarely needed to use it. He smoked half a pack of cigarettes each day and drank socially a couple of times a month.

One afternoon, John’s company notified him that it was laying him off along with more than a hundred other employees. Though he was devastated about losing his job, John was grateful that he and his wife had some savings that they could use for rent and other bills, in addition to the unemployment checks he would receive for a few months.

John searched aggressively for jobs in the newspaper and online, but nothing worked out. He began to have feelings of anger and worry that led to panic. His self-esteem fell, and he became depressed. When John’s wife was hired to work part-time at the grocery store, the couple felt better about finances. But demoralized by the loss of his job, John started to drink more often.

Two beers a night steadily increased to a six-pack. John and his wife started to argue more often. Then, about six months after losing his job, John stopped receiving unemployment checks. That week, he went on a drinking binge that ended in an argument with his wife. In the heat of the fight, he shoved her. The next day, John’s wife took the children and moved in with her parents. No longer able to pay the rent, John was evicted from the apartment.

John tried to reconcile with his wife, but she said she’d had enough. Over the next few months, John “couch-surfed” with various family members and friends. At one point, he developed a cold, and when it worsened over a few weeks, he sought care at the emergency department. The hospital staff told him that he would be billed because he didn’t have insurance. John agreed, and a doctor diagnosed him with a sinus infection and prescribed antibiotics. With no money to spare, John could not get the prescription filled.

John continued to live with family and friends, but his heavy drinking and anger only got worse, and his hosts always asked him to leave. He went from place to place. Finally, when John ran out of people to call, he found himself without a place to stay for the night and started sleeping at the park.

One night when John was drunk, he fell and got a cut on his shin. The injury became red and filled with pus. John was embarrassed about his poor hygiene and didn’t want a health care provider to see him. But when he developed a fever and pain, he decided to walk to the nearest emergency department. He saw a provider who diagnosed him with cellulitis, a common but potentially serious bacterial skin infection, and gave him a copy of the patient instructions that read “discharge to home” and a prescription for antibiotics. John could not afford the entire prescription when he went to pick up the antibiotics, but he was able to purchase half the tablets.

Winter arrived, and it was too cold for John to sleep outside, so he began staying at a shelter run by the church. Each morning, he had to leave the shelter by 6 AM. He walked the streets all day and panhandled for money to buy alcohol.

One evening, some teenage boys jumped John in the park, stealing his backpack and kicking him repeatedly. An onlooker called 911, and John was taken to the emergency department. Later that evening, the hospital discharged John. He returned many times to the emergency department for his health care, seeking treatment for frequent colds, skin infections, and injuries. Providers never screen him for homelessness and always discharge him back to “home.”

One day at the park, an outreach team from the local Health Care for the Homeless (HCH), one of about 250 such non-profit organizations in the United States, approached John. The team, including a doctor, nurse, and caseworker, introduced themselves and asked John, “Are you OK?” John didn’t engage. They offered him a sandwich and a warm blanket. John took the food without making eye contact. The team visited John for the next several days. John started making eye contact and telling the team about his shortness of breath and the cut on his arm. The team began seeing John frequently, and he began to trust them.

A couple of weeks later, John agreed to go to the HCH clinic. It was the first time in years that John went to a health clinic. Upon his arrival, the staff at the clinic registered him and signed him up for health insurance through Medicaid and food benefits. John felt comfortable in the clinic, and he saw some of the people who also stayed at the shelter and spent their days in the park. They were happy to see him and told John about how the clinic staff care and would be able to help.

John began going to the HCH clinic on a regular basis. He saw a primary care provider, Maggie, a nurse practitioner. In John’s words, she treated him like a real person. In addition to primary care, the clinic offered behavioral health services. Both scheduled appointments and walk-in care were available. John connected with a therapist and began working on his depression and substance abuse. A year later, John’s health has improved. He rarely needs to go to the emergency room. He is sober and working with a case manager in finding housing.

Discussion Questions:

1. What events in John’s life created a “downward spiral” into homelessness? Which events related to social needs, and which could health care have addressed?
2. What were some of the barriers John faced in accessing health care?
3. Why do you think the emergency department was the first place John thought to go for care? How might the emergency department improve care for patients like John?
4. Why do you think John wouldn’t make eye contact with the HCH team at first? How would you build a trusting relationship with a person like John?
5. What aspects of HCH care do you think represent high-quality care for the homeless? How do you think Maggie made John feel like he was a “real person?”
6. In your own experience, have you encountered a homeless individual? What was that like? Do you recall what you were thinking?

​​Remember some of these questions are Two questions in One. Ensure you answer all completely (detailed) but does not need to be a novel.

Answer 1

1. sudden lose of job was the main event in John's life created a" downward spiral" into homelessness.

lose of jobfinancial Crisis psychological& physical problems Relationship issues Isolation(homelessness)

Social needs which affected :- * A feeling of control over your life *self-esteem and self-confidence

* professional identity *daily routine *Purposeful activity

*Friendships and a work-based social network *family’s sense of security

Health needs :- * Psychological and physical issues -anger , depression, loss of self esteem

physical issues related of alcohol abuse , physical injuries and cut and poor hygiene 2. barriers John faced in accessing health care :-

a. Financial problems

b. Alcohol abuse

c.  The unwillingness due to embarrassment about his poor hygine &Feelings of shame, low self-esteem of being homeless

d. lack of knowledge and ignorance

e. lack of family support

3. Emergency department was the first place John thought to go for care because he was having fever and pain .Initially he was not ready to visit health care provider as he was embarrassed about his poor hygiene and was unaware of consequences due to negligence of health and healthcare needs.

Patients like John need both physical and psychological attention .He needs shelter , proper care , love and affection  etc. Emergency departments only take care of his present physical injuries and needs . He needs more help like Shelter-Based Clinics, Rescue Missions, Nonsectarian Programs ,The Public-Private Programs , etc at  present, there is one federally funded program, Health Care for   the Homeless    (HCH), that is designed specifically to provide primary health care to homeless persons.

4. John didnt made eye contact with HCH team at first because he was so embarrassed about his poor hygine , his mental state so affected due to his present condition , lose of job , alcohol abuse , relationship issue , homelessness all resulted in low self esteem , depression more over he was attcked by some antisocials that might scared him too .

to build trusting relationship ;-  Basic needs are critical like food, shelter, clothing and medical care, and gifts etc.

*  Approach with compassion, concern and acceptance

* Holistic Approach

* Effective Communication

* Support & Active listening  

*Empathy and positive regard. ...

5. HCH team team included Doctor , nurse and case worker that make it effective one .

* They showed concern and compassion towards John  by asking Are You Ok ?

* Provided Physical needs like food and warm blanket

* They visited him again for follow up care and to developed a trusty relationship with him

* Provided health insurance for future health needs

* Allowed John to see people like him and allowed him to mingle with them and to communicate their feelings

* Primary care provided Via nurse practitioner

* behavioural health services

Maggie made him feel like he was "real Person" via treating him as a human being , with love and affection , showing acceptance , active listening to his problem,

6. I have such experience 2 years before ..while working with a old age home encountered a homeless individual with some memory issues wandering on road. later provided him medical attention and send him to hospital for better treatment with help of NGOs