Search results and study characteristics
In total, 330 titles and abstracts were screened and 37 published review articles were deemed to meet the inclusion criteria and these then underwent full-text review. Next, during the data extraction phase with a close reading of each article, it was determined that 13 of the 37 articles that were initially included in the analysis did not fully meet relevance and/or rigour standards and they were thus excluded leaving a total of 24 articles for inclusion. All studies included in the reviews were from high income countries, the majority having focused on the USA, Australia and the UK.
Focus of the review
Initial analysis resulted in two broad conceptual sets of findings: one related to how services are organised and delivered and another related to how staff are trained and developed to best provide such services. Based on team discussions and with the recognition that we would not be able to fully explore all findings, the team decided to focus on the topics most relevant to the research question. The findings around service delivery and organisation were chosen as the focus for the next stage of the review.
Programme theories and CMOCs
Within the focused section of the review, a total of 59 CMOCs were generated. These theorise about the generative causation between each of the contexts and the specific mechanisms that fire within them to produce intermediate outcomes and the ultimate outcome of facilitating appropriate healthcare access. There was overlap between these but it was important to capture and articulate the relationship between each distinct context, mechanism and outcome and to interrogate whether they shared a causative relationship before combining them together.
Building on the 59 individual CMOCs, three consolidated CMOCs explain how health systems and individual health services make themselves accessible in relation to how healthcare is organised, the culture in a healthcare system and in healthcare organisations, and how healthcare is delivered.
To further investigate questions related to health services funding which was mostly absent from the peer-reviewed literature, a further fourteen individual CMOCs were constructed from data from grey literature sources. These were again consolidated resulting in the development of another three consolidated CMOCS explaining aspects of resourcing, funding stability, and system fragmentation and goals.
The six CMOCS are described in detail in the narrative below.
This first consolidated CMOC (fig 3) explores contexts where mainstream health practitioners and staff (in hospital and primary care settings) are expected to treat long-term homeless populations with high needs even if they receive no specialist training and health system budgets assign inadequate funding.(26–29) In these contexts, practitioners and staff feel ill equipped to communicate effectively with and meet the specific needs of the patient group. They experience feelings of inadequacy and lack of professional confidence and display an unwelcoming attitude toward patients.(13,26–28,30–34) As a result, patients do not feel comfortable and choose not to seek care at an appropriate time (eg seeking care early from a GP before a condition gets worse and acute care is needed).(13,26,31,35–37)
The outcome of not seeking care when the care environment is not welcoming becomes a new context which leaves patients instead to seek care only when the need is emergent and out of desperation, and at a later stage than ideal and at a setting that is available (such as the ED).(13,31,33,35,38) This results in the need for the health system to provide more care at a later stage and more intensive care and it generates poorer health outcomes and higher overall costs to the health system.(31,35,39)
Funding stability and source
CMOC2 (fig 4) shows that in a context where funding comes from multiple sources and where funding cycles are short and unreliable, eg grant funding for specific purposes with a short duration,(32,35,37,40) staff members employed on short term contracts experience poor working conditions with a lack of sustainability and stability of the services they work for.(29,37,41–43) The outcome is difficulties hiring and retaining skilled and experienced staff members.(29,37,41–43)
Health system fragmentation and goals
CMOC3 (fig 5) shows that in a context where various parts of a health system operate in silos with narrowly defined goals,(31,32,35,37,44) staff prioritise meeting those goals even though they are not suitable for responding to the complex needs of homeless patients whose care should be organised across a number of domains.(31,32,44) Staff and providers are not incentivised or empowered to take responsibility for creating holistic, coordinated flexible ways of organising care around a patient’s needs and wishes. As a result, healthcare is organised around the needs of providers and the system not the person.(14,31,32,35,44,45)
Care organised around the person
CMOC 4 (fig 6)shows that in a context of where care is organised around the person, the mechanism of flexibility and personalisation is triggered, allowing patients to feel that their particular needs are understood and met.(21,29,33,44,46–49)
Health system navigability is enhanced through having coordinated and co-located care,(7,29,33,34,47,50–52) through having clear and intuitive patient pathways managed by staff and providers who bring patients along to the next step, (14,33,47,53,54) and through accompanying patients either by link workers or peer advocates.(21,33,54–58) Having this kind of support helps patients by providing extra motivation and confidence in seeking health services when needed and navigating institutional locations such as hospitals and clinics, and negotiating patient pathways which may be complex.(33,35,47,54) Peer advocates have a unique understanding of the experience the patient is having and have the ability to meet patients where they are and provide emotional support.(33,38,52,55–57)
When care is organised around the person it is inherently respectful of other demands on their time and their particular goals (or lack thereof) for their own health. For example, as many services are carried out in one clinical encounter as possible and through shared and transparent decision making. As a result, responsibility is placed on the service to make itself fit with the patient’s life circumstances and to share knowledge and decision making to promote initial accessibility and beyond.(21,33,51,53–56,59)
Inclusive culture and leadership
CMOC 5 (fig 7) examines the importance of culture and leadership in creating health system contexts. Through culture the value assigned to different population groups is implicitly defined and, crucially, creating the right cultural context depends on leadership and management through explicit commitments to values of inclusivity and whole organisation policies and processes.(27,31,35,37,45,60–62)
In the articles reviewed, stigma is a crucial mechanism which keeps individuals experiencing homelessness from accessing healthcare (13,14,21,29,33,52,55,63). On the other hand, when individuals experience an environment that is non-stigmatising, respectful, empathetic, accepting, sensitive and understanding of their life experience and particular needs, trust develops and leads to a relationship developing over time whereby deepening trust facilitates ongoing engagement which leads ultimately to successful access to health services at the right time and right place.(33,34,46–48,51,55–57)
Flexible healthcare delivery
CMOC 6 (fig 8) explores the context of flexibility in healthcare services delivery in terms of appointment length, availability of walk-in appointments and self-referral, opportunistic add-on services such as vaccinations and screenings, allowing dogs, trauma-informed practice and understanding of behaviours that trauma can result in, and more.(21,26,37,40,46,47,50,51,55,64–67) In this context, providers and staff with expertise and experience with the population group are able to anticipate the common interventions that may be needed, to adapt to the particular needs of the patient in front of them, and to provide the treatment that is most needed in the current situation. Communication is tailored to the patient with awareness of potential literacy issues common in the population.(33,34,38,48,53,54,56,59,68) As a result, patients’ needs are identified and if met in the manner described in CMOC4, this experience forms a new context. In this new context (‘needs identified’), experiences of lowered frustration and fear is engendered in patients because they do not have to fit into a mould of a health service which is difficult to navigate and not likely designed with them in mind.(34,38,46,50,51,55) Resulting from that, patients feel seen and understood which becomes a new context (‘patients feel seen and understood’) in which ongoing engagement from both sides is possible and pathways can be created with high levels of flexibility and assistance.(38,46–48,55) Patients are able to follow these peer, key-worker and/or health staff assisted pathways and ultimately this leads to ongoing healthcare access over a course of treatment or on an ongoing basis as needed. A cyclical nature of an ongoing and trusting relationship is established and reinforced over multiple interactions.(21,33,38,55–57,67,69)
The overarching programme theory synthesising the full set of findings from this review (fig 9), shows that a set interlinking factors must all be in place for healthcare access to be successful for populations experiencing homelessness.