Are We Failing the Homeless and Uninsured Trauma Patient? An Exploration in the Nurse Practitioner Role in Trauma, and Identification of Disparity in Treatment and Barriers to Follow-up for the Acutely Injured

Abstract

The purpose of this dissertation was to examine disparities in healthcare related to insurance status and homelessness through three scholarly projects. Within the projects, the nurse practitioner’s role for trauma care in the homeless was reviewed. Two additional studies were conducted to identify if there is disparity in care for acutely injured patients based on insurance status at a national and/or a local level. Project I described the Trauma and Homelessness Initiative, which showed that essentially all homeless persons are exposed to trauma and then outlined a basic program that can be utilized to help care for those persons. Nurse Practitioner attributes were then reviewed and show that the nurse practitioner is well positioned to implement and lead similar programs. Project II was a secondary data analysis of a large national database (the National Hospital Ambulatory Medical Care Survey). Insurance status was associated with the number of patients returning to the emergency department within 72 hours of initial discharge for those who suffered an acute injury. When controlling for demographics and other variables studied, minority race and homelessness significantly associated with return visits. Project III was an exploratory, retrospective chart review performed to determine if lacking insurance is associated with the occurrence an adverse event prior to being able to obtain surgical correction of an unstable ankle injury. In patients seen at one of two emergency departments within a single healthcare system, neither insurance status nor demographic factors were associated with an increase in adverse events. There were more patients admitted from the emergency department than expected, which could be one explanation for the lack of disparity found. Evidence from these studies could provide nurses with knowledge about populations that face healthcare disparity. As primary patient care advocates and bedside healthcare providers, nurses, including advanced practice nurses, can use this knowledge to work toward providing the best care to all patients, regardless of their socioeconomic status or social situation.