Enhancing Interprofessional Community Engagement through Community-Based Participatory Research Strategies: Care Transitions for Patients Experiencing Housing Instability

Background. Transitions of care are high-risk periods for adverse outcomes, especially for people experiencing homelessness due to unstable housing, limited care access, and fragmented support. Medical respite care provides a safe and stable environment to recover from post-hospitalization and connections to essential medical and social services. At one large midwestern university, there is a strong commitment to community health improvement and engagement of health professional students in community-based interprofessional practice and education. This setting provides an opportunity to work collaboratively with the medical respite care, health systems and clients, to assess health-related needs using the community-based participatory research (CBPR) framework in authentic learning environments. Aim. To determine the facilitators and barriers to medical respite care transitions for people experiencing housing instability using CBPR-informed community health needs assessment (CHNA) approach. Methods . CBPR involves six phases: partnership, assessment, planning, implementation, evaluation, and dissemination. The CHNA includes ten steps: designing the assessment plan, building relationships, creating the community profile, assessing health equity, prioritizing community assets and needs, planning an equity strategy, developing an action plan, implementation, evaluation, and dissemination. We began with the partnership phase of CBPR by incorporating relationship building and assessment plan development. Design . A qualitative prospective study using one-on-one key informant interviewing. Participants . Collaborators who work with medical respite care in both client care and referral capacities. Data collection. A semi-structured interview guide was used to collect information virtually. Data Analysis. The audio recorded interviews were de-identified, transcribed, coded, and analyzed by thematic analysis. Results. Thirteen collaborators comprised of physicians, nurses, and social workers participated in the study. Five major themes emerged including structural and system-level factors (e.g. policy-practice gaps, human and infrastructure resources); care access and continuity (e.g. point of care entry, interprofessional practice and education); social determinants of health (e.g. housing, transportation and communication); interorganizational collaboration and community partnerships (e.g. community engagement and awareness, institutional collaborations); and population health trend (e.g. patient experience and engagement, morbidity and multimorbidity). Conclusion. Medical respite care programs significantly improve health outcomes for people experiencing housing instability; however, persistent system, community, and individual barriers remain and require coordinated, collaborative solutions.