Training Students as Navigators for Patients Experiencing Homelessness

Despite the significant impact of homelessness on health,^1-4 most medical and health professions students receive no formal education in caring for homeless populations.^5-7 Patient navigators, who work directly with patients to overcome health barriers, have been shown to provide substantial benefit to underserved and homeless populations, including reduction in health disparities and all-cause mortality.^8, 9 Medical students rely primarily on free clinic volunteering to learn about homeless healthcare, which has been shown to supplement medical education by improving student attitude and knowledge in working with people experiencing homelessness.^10, 11 We sought to build upon these principles by coupling a unique volunteering opportunity with formal education in patient navigation specific to the local homeless community.

The Patient Navigator Program (PNP) for Individuals Experiencing Homelessness and its prerequisite training elective were developed by students at the University of Texas Southwestern Medical Center (UTSW) in partnership with the UTSW Department of Family and Community Medicine and Union Gospel Mission (UGM) homeless shelters. The program connects residents of the homeless shelters with student navigators trained in patient-centered problem solving, the identification of local resources, and addressing barriers faced by individuals experiencing homelessness (Figure 1). Beyond generating a capable cohort of patient navigators serving the community, our goal in implementing the elective is to improve the capability of future health care providers in serving homeless and underserved populations throughout their careers.

Curriculum design was informed by a review of homeless health and patient navigator program curricula,^11-15 individualized to PNP with recommendations from UGM leaders and UTSW faculty. The PNP elective is an optional course available to medical and health professions students in any year of study, though it is primarily designed for preclerkship students without clinical experience. Students who complete the course are given the option to serve as a navigator for 1 year, starting the following semester. The course consists of seven 2-hour sessions throughout 1 semester, each session composed of one hour of didactics and 1-hour of program-specific training. Didactics are led by community experts, including health care providers, social workers, community outreach workers, and directors of homeless organizations; program-specific training was taught the first year by PNP student leaders who actively assisted in program development, and will be taught in following years by active student navigators (Table 1).

Students planning to serve as navigators were required to complete an anonymous linked RedCap survey delivered via email at two separate time points: prior to the first session, and immediately following the final session. The survey consisted of demographic questions, questions assessing career goals, and two externally-validated instruments: Health Professionals’ Attitudes Toward the Homeless Inventory (HPATHI)¹⁶ and the Student-Run Free Clinic Project (SRFCP) survey.¹⁷ This study was approved by the Institutional Review Board at UTSW.

Paired t tests and Wilcoxon rank sign tests assessed statistical significance differences of pre- and postcourse results. Statistical tests were two-sided, and a P value of <.05 and was considered significant. We performed all analyses using IBM SPSS Statistics, version 24.0 (IBM, Armonk, NY).

All students enrolled in the course also completed required anonymous UTSW-administered end-of-curriculum evaluation forms through RedCap software, delivered via email, consisting of nine core Likert-scale questions to assess course objectives, content, organization, and clinical relevance. The second half of the form, which was optional, consists of 12 open-ended questions evaluating student satisfaction.

Two authors reviewed responses to open-ended questions and independently identified themes through an open-coding approach. They then approached consensus regarding thematic categories and representative quotes, used to supplement and contextualize quantitative data.

Characteristics of student participants are highlighted in Table 2 and Table 3. Fifty-six students enrolled in the elective during its pilot implementation in fall 2020, with 46 students choosing to serve as a student navigator for 1 year following course completion. Of these students, 46 completed the presurvey and 45 completed the postsurvey. In the presurvey, a large proportion of students reported interest in working with individuals experiencing homelessness (25, 54.4%), low-income individuals (35, 76.1%), and racial/ethnic minorities (37, 80.4%). However, 52.2% (24) reported less than 1 month of experience working with or volunteering directly among individuals experiencing homelessness.

Pre- and postsurvey scores of self-assessed attitudes, skills, knowledge, and efficacy are shown in Table 4. Students who participated in the elective demonstrated an increase in self-assessed social advocacy (P<.001) and total HPATHI score (P=.03), indicating an overall improvement in self-perceived attitude toward individuals experiencing homelessness. Per SRFCP survey results, students also demonstrated an increase in self-perceived knowledge about underserved groups (P<.001), and self-efficacy in caring for underserved groups (P=.01). The largest overall score increase was reported in self-perceived skills in caring for the underserved, with an average Likert score average of 2.86 preelective and 4.17 postelective (P<.001).

Review of anonymous student feedback through the end-of-curriculum evaluation forms (56) indicated high student satisfaction, with 94.6% (53) agreeing that they would recommend the elective to future students. Of these 56 students, 27 elected to answer the optional open-ended questions, with responses summarized in Table 5.

Students who participated in this novel elective demonstrated significant improvements in self-assessed attitude toward homeless populations; they also reported increased self-perceived knowledge about, efficacy in treating, and skills in caring for underserved populations. The increase in reported social advocacy indicates an increase in student belief regarding society’s responsibility in caring for the homeless, likely due to curricular emphasis on systemic barriers to care. Of note, the largest score increase was seen in self-perceived skills in caring for underserved groups, which we believe can be attributed to the elective’s focus on motivational interviewing, helping patients set actionable goals, establishing professional boundaries, and practicing cultural sensitivity.

There are several limitations to this study. First, the study relied on students’ self-assessment of their attitudes and abilities, which is subject to cognitive bias. Additionally, the course was implemented at the beginning of the COVID-19 pandemic, requiring adaptation to a virtual format, possibly affecting curriculum efficacy. Finally, we collected data immediately before and after completion of the elective; therefore, the long-term effect of this training on students’ perception of their future attitudes and skills is not known. Future studies will include survey administration at a third time point to assess if this improvement remains consistent throughout the year of PNP service that follows the course.

Next steps will focus on continuous program monitoring and improvement. We aim to increase student satisfaction in elective format, and are preparing to transition to in-person didactic and service learning. Throughout the year, we plan to optimize elective objectives by seeking feedback from our inaugural cohort of navigators, the clients they serve, and the leaders at UGM. This study suggests that formal education through competency-based lectures, emphasizing patient navigation principles specific to the local homeless community, is effective in increasing self-perceived preparedness to serve both as patient navigators and future health care providers to homeless and underserved populations.