FormalPara Clinician’s capsule

What is known about the topic?

Patients experiencing marginalizing conditions often lack access to phones, which can hinder connections to follow-up care and services post-discharge.

What did this study ask?

What are the potential outcomes associated with prescribing mobile phones to patients experiencing marginalization in the ED?

What did this study find?

Phone provision can build trust with patients, facilitate referrals and follow-up care, and mitigate moral distress among healthcare workers.

Why does this study matter to clinicians?

Prescription mobile phones may improve care post-discharge, but key contextual and operational factors must be considered for future implementation.

Introduction

People experiencing homelessness and marginalization face considerable health inequities, including barriers to accessing healthcare and increased morbidity and mortality [1,2,3]. They tend to receive a disproportionate amount of care via Emergency Departments (EDs) [4,5,6] and have higher rates of readmission and ED revisits [5, 7, 8], largely because they lack access to primary care [9,10,11], and because hospital discharge and follow-up planning fail to account for their unique needs [12, 13], creating a “revolving hospital door” [14]. Increased reliance on technology in healthcare has exacerbated disparities, particularly since the COVID-19 pandemic [15,16,17]. This “digital divide” has resulted in disadvantaged populations facing heightened barriers to healthcare and poorer health outcomes [18]. Follow-up communication has long been challenging for people without fixed addresses or phones [19], and recent shifts to virtual care have inadvertently excluded those without access to technology or the Internet [3, 16, 20]. Thus, the concept of digital exclusion has emerged as an important determinant of health [15, 16, 21].

In response to the growing digital health inequities and communication challenges during the COVID-19 pandemic, an ED-based prescription phone program was developed to provide mobile phones to patients experiencing social and digital exclusion [22]. The program aimed to facilitate follow-up care, improve communication, and enhance connection to services for patients post-discharge. Very few phone provision interventions have been studied: one pilot program in the UK found distributing mobile phones to ED patients experiencing homelessness enabled better connection to services[23], and one study found providing cell phones or tablets to US veterans living in supportive housing helped them engage in healthcare[24]. This is the first known hospital-based program in Canada to provide free mobile phones to patients to facilitate follow-up care and access to services. In this study, we explored healthcare workers’ experiences with program implementation and outcomes, including contextual and operational facilitators and barriers. Through this, we sought to understand whether and how mobile phone provision can reduce digital health inequities among marginalized populations, and how to optimize future implementation efforts.

Methods

Study design and setting

PHONE-CONNECT (Phones for Healthier Ontarians iN EDs-COvid NEeds met by Cellular Telephone) is a hospital-based program that provides mobile phones to patients experiencing marginalization to facilitate follow-up care post ED-discharge. It was founded in March, 2020 by Emergency physicians at the University Health Network in Toronto, Ontario and expanded to two other Toronto inner city hospitals [22]. The program aims to improve patient outcomes by enabling connections to outpatient healthcare (e.g., primary care, specialist appointments) and community services (e.g., shelters, case workers). Healthcare workers in the EDs offer phones with 6-month plans to patients who do not have personal phones who they think could benefit from one. The phones are activated before discharge and the phone numbers are added to the patients’ medical records.

This study is one component of an evaluation of the PHONE-CONNECT program. Using a constructivist approach, we examined the experiences of healthcare workers involved in the program to understand how the program operated in practice. Patient perspectives and outcomes will be explored separately. Data for this study were collected from August to December, 2022 at two urban, inner city, academic hospitals in Toronto, Ontario: University Health Network and St. Michael’s Hospital.

Participants and sampling

As part of our broader evaluation, a survey was distributed to all healthcare workers in the hospitals’ EDs to gather their views on the program. This survey was sent via email and delivered to the EDs in hardcopy by two research coordinators not involved in program administration. Respondents indicated if they had direct experience with the program and if they consented to be contacted for an interview. We purposively selected those healthcare workers involved in the program for interviews, aiming for heterogeneity of roles where possible, including physicians, social workers, and peer support workers. We recruited participants via email and offered a gift card honorarium for participation.

Data generation and analysis

Two authors (GG and BB), familiar with the program but not known by participants, conducted in-depth interviews with participants, in person or via Zoom, using a semi-structured guide. Interviews focused on participants’ experiences with the program, perspectives on program outcomes, views on how and why the program worked, including contextual factors influencing outcomes [25], as well as implementation challenges, strengths, and suggestions for improvement. Interviews lasted 30–60 min, and were audio recorded and transcribed verbatim.

Two other authors (KH and CJP), external to the program and experienced in qualitative research, conducted reflexive thematic analysis [26] using a narrative approach wherein the unit of analysis was stories told by participants [27]. Analysis involved first reading the transcripts fully, then coding them inductively, identifying and refining themes, and producing interpretive findings based on the themes [26]. KH first analyzed five transcripts to develop initial codes and analytical memos, which were then refined through discussions with CJP. A draft thematic framework was developed to describe perceived outcomes and contextual enablers and challenges associated with the program. This framework was iteratively updated through analysis of the remaining transcripts and discussions between analysts (KH and CJP). The full team reviewed the themes for coherence and resonance at two points during analysis to provide clinical expertise and contextual perspectives to the findings. Analysis was deemed complete when thematic sufficiency was reached.

We engaged in reflexivity throughout data generation and analysis, acknowledging how our unique lenses and roles as clinicians or healthcare researchers may have shaped the research process. Utilizing a lead analyst external to the program helped enable an openness to the data, and using large, unfragmented segments of narrative data during analysis helped mitigate inadvertently misrepresenting participants’ meanings in our interpretation.

Ethics

We received ethics approval from the University Health Network Research Ethics Board (Protocol 20-5505) and a formal waiver from the St. Michael’s Hospital Research Ethics Board.

Results

Participants were 12 healthcare workers (demographic characteristics in Table 1). We identified five main interrelated program outcomes, as well as key program enablers and challenges. These findings are described below and depicted in Fig. 1, with additional supporting quotes in Tables 2 and 3.

Table 1 Participant demographic characteristics
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Fig. 1
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Perceived program outcomes, contextual enablers, and operational challenges

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Table 2 Perceived program outcomes
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Table 3 Contextual enablers and operational challenges
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Perceived outcomes

Building trust

Participants described the phone connect program as a tool to build trust with patients. By offering patients a phone, participants felt that they could demonstrate commitment to patients’ well-being and establish a trusting relationship. This foundation facilitated patients’ receptivity to the care offered, promoting uptake of the recommended healthcare services.

“It says a lot if someone says to you, ‘How am I going to organize my follow up?’ And you say ‘Well, I’m giving you a tool to do that.’…that builds a lot of trust… and I think that’s a facilitator of the entire rest of the engagement” University Health Network-002

Participants noted the program not only helped to build trust in their initial patient–provider interactions, but also facilitated long-term connection and support.

Facilitating patient independence

Upon building trust with patients, participants found that providing phones encouraged patients to take active roles in their care. While patients’ social situations can hinder their sense of independence, obtaining a phone can help them connect to services themselves and regain independence in their healthcare decisions.

“People are feeling neglected, forgotten about, excused. Phone-Connect provided them with… the opportunity to, on their own, choose if they wanted to continue on with their therapy, if they wanted to speak to someone.” St. Michael’s Hospital-004

Participants observed that phone provision also helped patients gain autonomy and independence in their personal lives, by accessing the internet or connecting with friends and family. Participants described the health benefits of social connection, noting the link between patients’ social connectivity and other positive outcomes, such as overcoming addictions.

Bridging care

Participants spoke extensively about their enhanced ability to follow up with patients, allowing them to effectively bridge care between the ED and other healthcare services. Since referral appointments are often finalized after discharge, providing phones helped to ensure patients successfully received those appointments and were connected to community services.

“Prior to Phone-Connect, if we were trying to connect somebody to a family doctor or to a caseworker, oftentimes that connection would never happen because they leave the emergency department… [and] they’re moving from shelter to shelter, so there’s absolutely no way for people to get a hold of them.” St. Michael’s Hospital-003

Due to improved patient follow-up, participants observed increased access to services, such as shelter, medical appointments, legal services, and case workers, with many describing specific examples of patients who benefited from the program. Participants noted the potential system impacts of patients’ increased access to services, including reducing unnecessary ED visits, since patients “don’t have to utilize the [ED] for their primary health care” (St. Michael’s Hospital-002), and potentially reducing hospital admissions.

Enabling equitable care for marginalized populations

Participants emphasized that providing phones is an essential first step in adequately serving patients experiencing marginalization. They stated the program enabled effective, equitable care for these patients by meeting some of their unique needs and addressing social determinants of health:

“It’s social supports, medical services, but all in all, it’s about… the social determinants of health. If people don’t have access to a GP, or a case worker or wound care, it ultimately is going to… impact their physical health down the road.” St. Michael’s Hospital-003

Participants conveyed the integral nature of phones for effectively treating patients, with one participant noting, “without the phone, it is very difficult to do this job” (St. Michael’s Hospital -002). Some noted that phone provision enables effective discharge and safety planning for patients experiencing marginalization, as phone possession is fundamental to these plans.

Mitigating moral distress among healthcare workers

By being able to provide effective, equitable care, participants expressed the program’s positive impacts on their own mental well-being and job satisfaction. Participants felt that the program supported their delivery of care by providing a tool to treat patients, alleviating their discouragement at being chronically unable to adequately serve this population:

“[The program] was very beneficial in the sense that it provided me with tools... Because not only can [homelessness and marginalization] be discouraging for… the client, it can be discouraging for your staff as well, because at some points you start to feel like you’re just pushing a rock uphill that's really slowly crushing you.” St. Michael’s Hospital-004

Participants noted that giving healthcare workers concrete tools helped mitigate the broader moral distress often experienced in emergency medicine.

Contextual enablers

Participants highlighted contextual factors that were key to program success (Table 3). Importantly, the program predominantly served underhoused patients experiencing complex, long-standing health and social issues, requiring specific follow-up care; the program was delivered in EDs well-versed in serving these populations. The healthcare workers in these EDs are familiar with the unique needs of this patient population and treat patients with “an open, non-judgmental, anti-oppressive framework” (St. Michael’s Hospital -001), which they felt was essential to building trust and connection. Seamless program enrollment was also felt to be critical for maintaining ED workflow while effectively serving patients.

Operational challenges

Participants discussed challenges and suggestions for program operations (Table 3). Program administration had not been fully formalized, so phone supply was inconsistent and eligibility criteria for enrollment were unclear, leaving staff uncertain as to who should receive phones and how many replacement phones could be given if lost. Participants suggested that more specific criteria and communication could clarify these parameters and mitigate potential bias in administering the program. However, they noted that determining criteria is difficult and nuanced, as it is unclear who should be excluded; while some patients’ precarious situations may increase their likelihood of losing phones, they may also benefit most from targeted follow-up care. Participants conveyed wanting to keep a “low barrier” for enrollment but recognized the need to prioritize patients due to resource constraints. They also noted that patients seeking phones might contribute to unnecessary ED visits and long ED wait times. Given these issues, as well as questions about ongoing technical support for the phones, some participants expressed feasibility and sustainability concerns; however, they emphasized that the operational challenges encountered were minimal compared to the program’s benefits.

Discussion

Interpretation

Our examination of healthcare workers’ perspectives suggests that providing mobile phones to patients experiencing marginalization in the ED may lead to important patient and system outcomes, including fostering trust with patients, facilitating patient engagement in healthcare, increasing access to services across care sectors, enabling equitable care for marginalized patients, and mitigating moral distress among healthcare workers. Our study highlights the interrelatedness of these outcomes and the influence of contextual and operational factors on program implementation and outcomes. Notably, simply providing phones may be insufficient; delivering the program in settings familiar with the care of marginalized patient populations, and establishing trusting relationships with patients using non-judgmental, anti-oppressive approaches, may facilitate its success. Additionally, ensuring seamless program enrollment within the ED through adequate phone supply, defined eligibility criteria, and clear program communication may support sustainability. Overall, participants expressed that phone provision is invaluable for patients facing barriers to accessing healthcare and social services, and for healthcare workers who lack resources to adequately serve marginalized populations.

Comparison to previous studies

This is one of the first peer-reviewed evaluations of a prescription mobile phone program for patients in the ED experiencing marginalization. Underhoused patients often face significant challenges with discharge and follow-up as discharge plans rarely account for risk factors associated with homelessness [12, 13]. Participants in this study reiterated that many discharge plans are ineffective for patients without phones, and that providing phones enabled successful follow-up and increased continuity of care across sectors, reducing patient reliance on the ED and potentially decreasing hospital admissions. Phone provision reportedly facilitated access to social services such as shelter, case workers, and legal aid. It also seemed to enhance patients’ social connectivity, which has considerable health benefits [28, 29], and may be invaluable for people experiencing homelessness who are susceptible to social isolation [30].

For patients experiencing homelessness, lack of trust is a common barrier to accessing care, whereas positive relationships with healthcare workers can facilitate healthcare utilization [3, 33]. Patients experiencing marginalization often feel unwelcome in healthcare environments, deterring them from engaging in healthcare [6, 36]; building trust using non-judgmental, anti-oppressive approaches is imperative [33, 37]. In this study, participants felt that this relational approach was foundational to the program, as phones were given in the context of empathetic interactions which promoted trust and encouraged patients’ engagement in the healthcare referrals. Such active engagement can improve treatment adherence, health outcomes, and satisfaction with care [38]. Additionally, building trust and reducing digital health inequities were rewarding for healthcare workers. Whereas experiencing patient mistrust and feeling constrained in providing adequate care can lead to moral distress [39, 40], having concrete tools to serve patients may facilitate fulfillment among staff.

Despite the positive perceived outcomes of the program, participants highlighted operational challenges that require attention. Notably, while they emphasized the importance of minimizing barriers to access, they recognized the need to put parameters around phone provision to ensure program feasibility and sustainability. Moreover, the absence of enrollment criteria could put healthcare workers in the undesirable position of determining who receives a phone, and potentially introduce bias into program administration. Implicit biases can influence clinical decision-making and outcomes, particularly in fast-paced, high-pressure settings [41] such as EDs. In response to these concerns, the eligibility criteria were subsequently narrowed to focus on patients newly connected to case managers, community health programs, or the hospitals’ addictions clinics, as these patients are the “highest risk repeat users” of the ED and have assigned follow-up workers who can aid their use of the program. This change in criteria aimed to facilitate integration of the program with minimal burden on ED staff [42], while prioritizing the highest need patients, recognizing that those at greatest risk of losing a phone are often those most in need of one.

Strengths and limitations

This was among the first studies to evaluate a prescription phone program. Our sample was small; however, we generated rich data and our rigorous reflexive analysis produced insights that may be transferrable in other contexts with similar patient populations. Our sample was predominantly female, reflective of the demographic profile of the program staff. Finally, our study focused on healthcare workers’ perspectives, which was an important first step in understanding whether and how the program works, and which factors may influence future implementation; patient perspectives and outcome measures will be examined subsequently to further elucidate program benefits and challenges.

Health system implications

Our findings have clinical implications for addressing health inequities and practical implications for future implementation efforts. Notably, providing phones should be in the context of a program, inclusive of relational care and a biopsychosocial understanding of health. Embedding this program in a setting well-versed in serving people experiencing homelessness and marginalization may facilitate its success [7]. Additionally, maintaining efficient ED workflow is important for sustainability; therefore, seamless program enrollment and clear communication about program purpose and eligibility criteria are needed. Future implementation efforts should focus on clear criteria that facilitate efficient and sustainable program enrollment while maintaining low barriers to phone access. Attention to possible bias in program administration may be necessary, particularly if implemented in contexts unfamiliar with treating patients experiencing marginalization. Overall, a non-judgmental approach to providing phones and replacing them if lost is encouraged.

Research implications

The benefits of addressing social determinants of health are well established [33,34,35], and the need to consider digital determinants of health is increasingly recognized [16, 21]. Our findings add to this knowledge base by demonstrating the positive perceived effects of providing phones to patients experiencing marginalizing conditions. Continued delivery and evaluation of prescription phone programs will build further knowledge on their potential role in addressing health inequities. Future longitudinal research is needed to examine the social, contextual, and operational factors that facilitate patient adherence and outcomes. Further research is also needed to explore patient perspectives and outcomes to comprehensively understand program impact.

Conclusion

We qualitatively evaluated an ED-based prescription mobile phone program for patients experiencing homelessness and marginalization in two urban hospitals from the perspective of healthcare workers. Our study highlighted positive perceived effects of mobile phone provision in addressing digital and social health inequities, and illuminated critical contextual factors to inform new iterations of the program. Ongoing research on patient perspectives and outcomes will further our understanding of the role of mobile phone provision in facilitating access to care and combating health inequities among marginalized populations.