Introduction
The current study is based on the findings of an action plan by the DHHS. The plan was geared at establishing and recommending effective measures of preventing homelessness through the use of evidence based interventions (U.S. Department of Health and Human Services (DHHS), 2003). For people with mental illnesses , the Federal Interagency Council established in a report in the year 1994 that most homelessness is caused by improper discharge planning. The Department of Health and Human Services in the United States highly acknowledges efforts geared at the prevention of homelessness. Discharge planning is a mechanism that provides guidelines on the transfer of individuals from one point of care to another. The process of discharge planning is implemented to ensure the efficacy and safety of the individuals being transferred. The process involves evaluation of the eligibility of the patient for discharge, establishment of the next care as dictated by the needs of the patient and establishing the existence of sufficient monetary resources. This study will examine the evaluative ability of discharge planning in the prevention of homelessness. A dependable survey will be carried out while employing the questionnaire as the main data collection tool. Based on what is collected, the researcher will carry out an analysis of the results to assist in drawing a hypothetical conclusion. A variety of data representation tools are available to be used within this research. Since the research dealt with the mentally impaired patients at the risk of being homeless, none of the patients was interviewed. Only employees in discharge planning programs and nursing professionals from various mental hospitals were interviewed. Specifically, the sample comprised of five nursing professionals and 20 employees drawn from different discharge programs. Therefore, the total sample for the research comprised of 25 nursing professionals and 100 discharge planning employees. A total population sample of 125 participants was used.
Chronic Homelessness
Studies done in the past have shown that many individuals with chronic mental problems are faced with homelessness. These individuals tend to move repeatedly through institutions. The latter is equally described as traveling in institutional circuits. Among the institutions in which mental patients will travel from in their life time are; mental hospitals, rehabilitation centers, prisons and residential points of care. The WHO in a report on mental treatment indicated that very few studies have evaluated the role of discharge planning in the prevention of homelessness (World Health Organization, 2005). This is, despite the fact that discharge planning is highly recommended as an intervention measure in the prevention of homelessness (Shepperd et al., 2004). Reports from previous studies also indicate that a large majority of homeless individuals emerge from psychiatric hospitals and various residential treatment centers (Kralik et al., 2004).
Selection of the Method
The components addressed in this study include the following; a literature review of the methods used in a qualitative data analysis and a review of several interview responses from some of the programs personnel. Other components of vital importance to the study will be; an analysis of the documents related to the process of discharge planning and a final report that will give a summary of the various key findings in a conclusion. Various methods can be applied in a study centered on discharge planning. The choice of the method is highly determined by the main objectives of the study and medical condition of the patient at the time of discharge (Holloway & Todres, 2003). It is equally important to identify the members of a discharge plan and subsequently state their responsibilities. In the evaluation of the state of the next point of care for the patient, a number of factors are considered. Key to these factors is the needs of the patient (Koch et al., 2004). It is expected that both the objectives of the plan and the needs of the patient are met in a cost effective way using readily available resources. Among possible points of care for mental patients are; acute and long term facilities of residency alongside the home of the patient (Holloway & Wheeler, 2010).
Available Methods
The commonly utilized methods in a qualitative data analysis include Ethnography and phenomenology (Christina, 2005). In ethnography, the main focus of the study is on groups of individuals as opposed to the study of individual subjects. This type of method may not be appropriate for my study since individual subjects have varying characteristics and would require different treatment options. This method eventually developed from the existence of common groups of individuals (Ploeg, 1999). While using this method, the researcher is normally interested in establishing how the individuals in a group interact with each other. When used to collect data in interviews, this method assumes that the entire study is meant to establish what the individuals in a group will experience (Liamputtong, 2009).
With regard to the use of discharge planning as a means of preventing homelessness, there is need to establish the eligibility of individuals for services provided by each program. Unfortunately the use of this method for the current study will not ideally establish the eligibility of individuals for the services offered by the various programs. This is because ethnography as a method seeks to establish the culture adhered to while seeking treatment options among individuals (Wilson et al., 2006).
According to Giorgi and Giorgi (2003), Phenomenology is a method of study that is formulated based on the concept of existence. While using this method, it becomes relevant to establish the existence and implication of some phenomena (Ashworth, 2003). This implies that the researcher in this study seeks to explain why certain phenomena exist without using theories. To make realistic judgment, a more powerful method is required. This is because the management of the state of homelessness is a critical aspect that requires more realistic methods.
The main sources of data in this study will be interviews and discussions with nursing professionals and related employees. Materials from the analysis of documentaries and some medical reports alongside the review of various procedures will also be used. The major limitations of the methods used in this study are the assumptions held by different experts regarding the suitability of their programs over others. Vital findings in the study are formulated based on qualitative examination of sample program sites. These program sites are such that they are selected just because majority of the program experts think that their programs are better than the rest. In this study, there will be no interviews involving clients. At the same time quantitative data will not be examined to confirm any of the reports from colleagues.
Individuals receiving foster care who later terminate this care prematurely happen to be at a higher risk of being homeless (Osher et al., 2002). An interview question based on early terminators will be geared at creating more knowledge regarding various appropriate ways of caring for the individuals at such a risk. The design of this study will be close to that used in the National Outcome Performance Assessment. The only difference will be the use of comparison sites but the same instrumentation will be used. In the study, it is also evident that various other strategies that are equally fitting in the prevention of homelessness can be utilized.
Statistical analysis
Demographic Analysis
This section highlights the analysis based on age and gender characteristics of individuals at the risk of being homeless as indicated by the interviewees. Descriptive analysis was used to ascertain the frequencies of these factors as shown in the two sections below.
Sample Size Determination
The purpose of the study will help determine the size of the samples to be used. A relatively large sample possibly in terms of several thousand will be used. To attain a significant statistical power, proper sample size determination is required. This is equally vital especially if a summative evaluation is to be done. The precise determination of the sample size requires a proper understanding of the objectives of the study and the design of the same study (Boult et al., 2003).
Table: Frequency analysis of the gender
From table the results indicate that of the 125 people interviewed in the study, 64 of them were male while the rest were female. The remaining 0.8% an equivalent of 1 represents the margin of error because of omitting some of the parameters which nevertheless were accounted for. Therefore, these results are representative showing a fair distribution of the gender which differs by small margins.
Age
This descriptive analysis shows the age in years of the sample selected which was categorized in groups as illustrated in the table below.
Table: Age in years
The table illustrates the age distribution of the sample. The age bracket of between 36 and 45 years constitutes 28.8% of the sample which represents 36 people out of the 125 sampled. The 66+ years bracket is the lowest having 5 respondents and representing 4% of the study sample. The bracket of age 46 – 55 years is equivalent to 16% representing 20 respondents of the sample. The remaining age brackets are fairly distributed as shown in the table.
Study Design
A study based on discharge planning requires the need to consider various measurable aspects and the entire design. Below are some of the factors that are essential in the design of a study based on discharge planning. Some of the measurable factors that may need to be normalized to attain a summative evaluation are also indicated. These factors have been structured in the form of questions that were posed to the interviewees. The normalization of the measurable factors is to be done with regard to the context and setting of the study. In this section, the various factors to be measured, and the collection of the data are discussed.
Qualitative data analysis
This chapter presents the data arising from the unstructured interviews with the nursing professionals and the employees from different discharging programs. Among the major interview questions in this study was to establish whether a significant evaluation of the ability of discharge planning in the management of homelessness is feasible. Other interview questions in this study included establishing if discharge planning is such that can be separated from other activities. Establishing the required period of follow up after discharge to establish an individual’s state of housing was another vital question. It was equally important to establish if any other alternative study designs can be considered when evaluating discharge planning. In this section various unstructured questions pointing to the variables that may affect the evaluative ability of discharge planning are posed to the interviews. The responses emerging from the interviews are discussed and summarized.
Recruitment of Clients at a Possible Risk of Homelessness
An initial interview question to employees from discharge planning programs on how clients at the risk of being homeless should be identified was posed. According to the responses, only subjects whose possible risk of being homeless is significant should be recruited. It also emerged that different discharge programs are designed to meet different needs of clients. Some programs are specifically designed to serve individuals at the risk of being homeless or those that are already homeless. For individuals who terminate their period of residency and later choose to return to these points of care, there are specific programs that can be utilized.
Measuring the Context of the Policy
This was a questioned that was posed to nursing professionals. According to their response; the policy context highly defines the operation of any given program. The conditions under which any discharge planning program operates are highly influenced by various regulatory bodies whose policies highly determine the type of services offered by a program. The implementation of various discharge planning activities is also determined to a larger extent by such policies.
Measuring of the Relationship of the Program to Other Organizations
How a discharge program relates to other programs is a question that was posed to the employees from various discharging programs. This is a relatively important aspect to be considered (Weinberger et al., 2006). For instance, if a program is related to another umbrella agency that offers any related form of care such as housing, it becomes easy to connect individuals with such agencies (Lutfey, 2005). Alternatively if the existing programs have good links with any community agencies, it becomes equally easy to access the services of such agencies (Scott, 2004). It emerged from this round of interviews that discharge program goals are directly related to other goals across institutions. It was observed from the responses that employees and management of discharge programs rely on effective communication with other institutions to achieve the goals of their programs.
Measuring the Available Housing Status and Other Related Supports
This is an equally important variable especially within the community in which the discharge planning program is to operate (Wilson et al., 2006). Responses from the discharge planning employees indicated that it is important to affirm that the existence of stable housing facilities highly depends on both the value of discharge planning and the existence of other vital resources. One of the employees particularly indicated that unavailability of such vital resources and housing facilities makes it relatively hard to attain good outcomes.
Measures To Effectively Monitor Early Terminators
According to nursing professionals, individuals who leave the care programs before the expiry of their time of residency are a problem to the evaluation of any discharge planning study. Various programs exhibit high rates of early termination yet measures geared at making any follow up to provide valuable data are limited (Sexton et al., 2009). Most of the individuals who possibly terminate their time of residency are at a relative high risk of being homeless (Dawson et al., 2008). The nursing professionals indicated that most of such individuals are very unlikely to get any appropriate treatment or possible discharge planning. It also emerged that such individuals are equally hard to enroll and subsequently follow in monitoring studies. However, if the main objective of discharge planning is to effectively manage homelessness, inclusion of such individuals is equally vital.
Data Collection and Tracking Infrastructure
For the study to effectively evaluate the state of homelessness, a commitment towards the use of appropriate data collection tools is required (Nazareh et al., 2001). When asked on how clients are monitored, both nursing professionals and the employees indicated the value of monitoring tools. A nurse from a mental hospital indicated that measures geared at making any follow up especially with regard to early terminators will also require data monitoring tools. The use of data that is already available may provide some vital information required for the evaluation of a discharge planning program. However another nurse indicated that such data may not provide all of the required information and most of such information is of different quality. Unfortunately, most of the data programs in existence may lack the resources required for effective follow up of individuals following discharge. Most of the programs that allow for the collection of data on follow up have response rates that are not ideal for effective evaluation (Macaulay et al., 2006). The provision of enough resources for appropriate data collection is thus vital to the evaluation of the ability of discharge planning to prevent homelessness.
Identification of Individual Demographic and Clinical Features That Need To Be Measured
The process of discharge planning is highly affected by variability in individual characteristics (Abramson et al., 2003). These differences will also affect the various options for discharging planners alongside the outcomes following discharge. When asked on how and what features are measured, the nursing professionals indicated that in the evaluation of a discharge planning program, key individual characteristics that need to be measured include the following; physical disabilities, the presence of psychiatric illnesses, history of drug or substance abuse and both past and current criminal history. The presence of emotional disorders alongside disorder pointing to the abuse of drugs should also be measured. The eligibility of individuals for any services and entitlements is also affected by both the clinical and demographic features (Mamon et al., 2005). Subsequently, these aspects will have an impact on the outcomes of a discharge planning program.
The Use of Separate Studies for Different Settings
The settings in the current study are designed to indicate discrete programs. This possibly hints at the need to establish the programs that need to be compared in the evaluation of discharge planning. The programs to be used in evaluating outcomes from each program setting should also be established. The settings in mental treatment programs will involve public mental hospitals, various mental units and some private mental hospitals (Holloway, 2005). The nursing professionals indicated that all of these mental units are such that they will have varying characteristics. The clients served at these inpatient mental units may also present varying risks of being homeless following discharge (Sachs et al., 2000). The entire process of discharge planning is thus affected by all of these characteristics. There might also be differences in the sub settings of the various programs as indicated by the employees drawn from different discharge programs. Unlike most of the treatment program settings to be evaluated, foster care programs are not necessarily treatment programs (Center for Substance Abuse Treatment (CSAT), 2005). Most of foster care programs are designed for the sole purpose of helping youthful individuals to live a proper life within the society (Health services performance improvement, 2011).
Conclusion
In this section, key findings as depicted in different program settings are summarized.
In the study it was established that a very vigorous process of evaluating discharge planning is not necessary at the moment. The recommendations cited in opposition to the need to conduct an evaluative summary of discharge planning were based on proper findings. Among the findings is that the process of discharge planning is such that they cannot be separated from the entire program. It was also indicated by majority of the interviewees that the cost of conducting a summative evaluation is very high and that there is very little understanding of the process. However it was also established that unlike the need for a summative evaluation, alternative studies that would possibly evaluate certain activities common to the process of discharge planning are feasible.
For each of the program settings, the possibility of separating discharge planning from the entire program was a key interview question. From what was gathered, various activities common to discharge planning are vital to the entire plan. Most of such activities are such that are performed by the same staff involved in discharge planning. These activities occur in the context of the entire treatment process and thus cannot be easily separated.
With regard to housing facilities and the available resources, the study established that the possibility of preventing homelessness depends on the availability of these two factors. This was an observation that was made with regard to properly established discharge planning programs examined by the study. The model of discharge planning used in this study was implemented in a rural setting where housing options are minimal. Most of the individuals were thus sent to semi-institutional settings following their discharge. Community housing is thus an aspect that cannot be over looked.
There are several discharge planning tracks in custodial programs that are highly determined by the source of funding coupled with their eligibility. Most of these planning tracks amount into varying periods of residency, clinical interventions and community housing options. For instance, the client’s eligibility for medical care and private insurance among others highly influence the type of discharge planning that the patient will get in a mental unit. For individuals in residential treatment centers, the process of discharge is highly determined by the welfare of the client and whoever has custody of the client. An individual evaluating the process of discharge planning is thus required to address all the complications common to discharge planning tracks.
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