Health Promotion Plan for Homeless Individuals in Inner-City Baltimore, Maryland Homelessness in Baltimore’s inner-city is one of the most pressing public health challenges today. As an ER nurse at the University of Maryland Medical Center, I regularly care for unhoused individuals who rely on emergency services as their primary source of healthcare. The firsthand experience has revealed the recurring cycle of untreated chronic conditions, mental illness, and substance use among the population, which is compounded by systemic barriers such as poor hygiene facilities, limited follow-up care, and inadequate housing options. According to the Mayor’s Office of Homeless Services (2024), over 1,600 people are homeless in Baltimore on any given night, facing elevated risks of exposure-related illnesses and environmental hazards, as evidenced by community assessments highlighting unsanitary living conditions and overcrowded shelters. The paper develops a realistic, evidence-based health promotion plan that addresses the three priority health needs of the vulnerable population by identifying key health problems, proposing three SMART goals, outlining targeted interventions, assessing available resources, defining the nursing role, and presenting an evaluation strategy to promote sustainable community health improvement for Baltimore’s homeless population. Developing an effective health promotion plan for Baltimore’s homeless population requires a targeted, evidence-based approach that addresses the intersecting challenges of limited healthcare access, untreated mental illness, and poor sanitation through collaborative, nurse-led community interventions. Population and Community Assessment The population and community assessment of inner-city Baltimore revealed a multifaceted public health crisis, in which homelessness intersects with environmental hazards, inadequate healthcare access, and social determinants that perpetuate health disparities and systemic neglect. Homelessness in inner-city Baltimore represents a critical public health concern, with over 1,600 individuals identified as unhoused on any given night (Mayor’s Office of Homeless Services, 2024). These individuals often contend with a combination of untreated mental illness, substance use disorders, chronic diseases, and exposure-related conditions that significantly affect their well-being. Epidemiological analysis underscores that many homeless individuals lack access to basic hygiene, consistent healthcare, and safe shelter, factors that contribute to repeated emergency department visits and poor health outcomes. A windshield survey revealed the visible manifestations of these issues, including encampments under bridges and in parks, makeshift shelters made of tarps and cardboard, and overcrowded shelters, reflecting the dire housing instability in Baltimore. Anderson et al. (2021) note that the crisis is compounded by locked or broken public restrooms, scattered trash, and unsanitary conditions that foster respiratory infections, skin diseases, and other preventable illnesses. These findings collectively highlight the urgent need for comprehensive, community-driven interventions that address the immediate health concerns and the underlying structural inequities contributing to homelessness in Baltimore. A closer examination of the underlying risk environment reveals how structural and environmental factors sustain health inequities. Deep-rooted poverty, underinvestment in infrastructure, and a shortage of accessible, low-barrier services leave unhoused individuals trapped in cycles of vulnerability. The absence of transportation to care facilities, nutritious food options, and safe community spaces further isolates this group from health-promoting resources. As noted in the windshield survey, the landscape of broken infrastructure and abandoned buildings not only represents neglect but also acts as a barrier to outreach and service delivery. Furthermore, social stigma and punitive policies often divert attention away from long-term solutions, such as housing, employment, and navigating the health system. These compounding issues necessitate data-informed, compassionate, and community-engaged approaches that go beyond surface-level fixes to disrupt the root causes of homelessness and promote equity in care access and outcomes. Identified Needs/Problems Based on epidemiological and field data, one of the most pressing health needs among Baltimore’s homeless population is limited access to consistent healthcare services. The Mayor’s Office of Homeless Services (2024) reports that many homeless individuals in Baltimore lack regular medical care and rely heavily on emergency departments for acute services. The windshield survey confirmed that the homeless lack regular medical care and rely heavily on emergency departments for acute services by noting that mobile health vans and outreach services were only occasionally available, with overall access to routine and preventive care described as “limited”. As a result, chronic conditions such as diabetes, hypertension, and asthma are often left unmanaged, increasing complications and hospitalizations. Geographic and structural barriers such as transportation issues, the absence of stable addresses, and mistrust in the healthcare system further isolate the population from primary care providers. According to Anderson et al. (2021), individuals experiencing homelessness also fail to adhere to treatment regimens due to competing survival needs, including food, shelter, and safety. Vo et al. (2023) further detail that epidemiological evidence also suggests that systemic neglect and the social determinants of health (SDOH) including unstable housing, low income, and social exclusion contribute to worsened outcomes and minimal engagement with preventive services. The persistent lack of coordinated, accessible healthcare contributes to a cycle of preventable illness and costly emergency care use, underscoring the urgent need for targeted, community-based health interventions. The homeless population in Baltimore faces compounding challenges from untreated mental health conditions, substance use disorders, and unsanitary living conditions that significantly undermine physical and psychological well-being. The windshield survey and observational data reveal signs of psychological distress and substance dependence among unhoused individuals in public spaces, shelters, and transit areas. Kelly (2020) identifies histories of incarceration, trauma, and emotional disturbances as major risk factors contributing to homelessness. These factors, combined with a lack of access to counselling, psychiatric medications, and addiction recovery services, result in ongoing cycles of crisis and instability. Moreover, poor hygiene and sanitation, a third priority concern, contribute to the spread of communicable diseases. Anderson et al. (2021) detail that overflowing trash bins, locked restrooms, and exposure to contaminated public spaces were common findings in field assessments, conditions that heighten vulnerability to skin infections, respiratory illnesses, and gastrointestinal outbreaks. These issues place a significant burden on public health systems, highlighting the need for integrated, trauma-informed, and community-specific health strategies. SMART Goals and Role of the Nurse To address the complex health needs of the homeless population in inner-city Baltimore, three specific, measurable, achievable, realistic, and timely (SMART) goals have been developed. Firstly, mobile health access will increase by 50% within 12 months for unhoused individuals in identified high-need areas, such as park encampments and bridge under crofts. The goal is based on observations from the windshield survey, which revealed limited access to consistent care, despite the presence of visible mobile health vans in only a few high-traffic zones. Secondly, the plan aims to reduce emergency room admissions related to mental health crises by 20% within one year through expanded outreach, peer support, and coordinated referrals. The Mayor’s Office of Homeless Services (2024) reported that many unhoused individuals suffer from untreated psychiatric and substance use conditions, often resulting in avoidable ER visits. Thirdly, access to hygiene will be improved by increasing the use of mobile showers and restroom units by 30% within nine months. Windshield observations revealed that many restrooms are either locked or unsanitary, contributing to the spread of communicable diseases. Expanding mobile health units and sanitation services will offer accessible, immediate relief while supporting long-term system navigation. These goals directly address data showing limited access to consistent care, particularly in underserved encampment zones where people often rely on emergency departments for their basic needs. Nurses will play a pivotal role in implementing the proposed health promotion plan for Baltimore’s homeless population, working across the continuum of care to operationalize interventions and address both immediate health needs and long-term social determinants of health. Within this plan, nurses will conduct preventive activities, including mobile health screenings, early referrals for chronic illnesses and mental health care, and education on hygiene and disease prevention. Promotively, they will engage with community partners to advocate for expanded mental health services and destigmatize care, particularly through peer-supported outreach. Curative roles will include providing wound care and medication management via mobile clinics and field-based triage. In addition, in their rehabilitative role, nurses will work alongside case managers to connect clients to housing, legal aid, and psychological support services, thereby helping to restore personal dignity and stability (Nursing Path, 2020; Lee et al., 2023). Morone et al. (2022) emphasize that in Baltimore’s Community Care Teams, nurses serve as vital connectors between clinical systems and community-based supports, ensuring that clients do not fall through the cracks. Through these targeted roles, nurses will play a crucial part in implementing the SMART goals and ensuring the success and sustainability of the health promotion strategy. Community-Specific Interventions and Resources Addressing homelessness in inner-city Baltimore requires an integrative approach that aligns health promotion with socio-environmental realities. The first intervention involves deploying mobile health clinics in areas with high concentrations of unhoused individuals. These clinics would provide essential services, including chronic disease management, vaccinations, wound care, and mental health screenings. According to the Mayor’s Office of Homeless Services (2024), over 1,600 individuals are homeless in Baltimore nightly, with limited access to consistent medical services. Epidemiological findings highlight that many use emergency departments as their primary care point, leading to avoidable hospitalizations and overburdened facilities. Research by Anderson et al. (2021) further details that the Baltimore Health Department and Health Care for the Homeless already provide outreach; however, scaling mobile services through geographic information systems (GIS) would enable targeted deployments to encampments and bus stops. By expanding mobile clinic outreach and leveraging data-driven tools like GIS, the intervention reduces system strain, enhances early intervention, and promotes equity in one of Baltimore’s most underserved communities. The second intervention focuses on peer-supported mental health and addiction outreach. Many homeless individuals have untreated mental illness and substance use disorders, worsened by distrust in traditional providers. Involving culturally competent peer specialists with lived experience can build rapport and deliver trauma-informed care. Partnering with Behavioral Health System Baltimore (BHSB) can facilitate training, coordination, and access to crisis stabilization units and detox services. Peer involvement fosters trust and continuity, key elements identified by Ms. Johnson, a community nurse in Baltimore who emphasized the role of empathy and consistency in engaging the population. The third intervention aims to improve sanitation by providing mobile showers and restrooms. Poor hygiene was evident in the windshield survey when public restrooms were locked or broken, and encampments were surrounded by trash and human waste. Anderson et al. (2021) contend that these conditions contribute to the spread of communicable diseases such as hepatitis A, lice, and skin infections. Thus, by collaborating with local nonprofits, churches, and mobile hygiene service providers, the strategic deployment of sanitation units can be ensured in high-traffic areas, thereby preserving dignity and reducing the spread of disease. Addressing the root of homelessness requires comprehensive housing navigation and case management services that extend beyond immediate shelter needs. Research by Kelly (2020) emphasizes that homelessness is linked to systemic factors such as poverty, untreated mental illness, and histories of incarceration, all of which demand long-term, coordinated interventions. Embedding case managers from programs such as the U.S. Department of Housing and Urban Development (HUD), Community Care Teams (CCTs), and local shelters ensures that unhoused individuals receive assistance in obtaining identification, enrolling in Medicaid, securing transitional or permanent housing, and accessing mental health or substance use treatment. Community health nurses and CCTs serve as essential connectors between clinical services and the broader social support network, ensuring continuity of care and reducing barriers to reintegration. Ultimately, strengthening housing navigation and case management not only promotes individual stability but also lays the groundwork for sustainable public health improvements and reduced reliance on emergency systems. Evaluation Plan A robust evaluation plan is crucial for measuring the success of the proposed health promotion interventions for Baltimore’s homeless population. The plan will integrate process and outcome metrics to assess the reach, effectiveness, and sustainability of services provided. Such initiatives, including mobile clinics, mental health outreach, sanitation improvements, and housing navigation, yield measurable benefits. Process metrics will focus on quantifiable service engagement indicators such as the number of mobile clinic visits per month, the volume of mental health referrals made and completed, and usage rates of mobile hygiene units. These metrics provide insight into how effectively interventions are reaching the target population and where service gaps may exist. Rather than simply tracking data collection methods, these process indicators will provide a snapshot of service delivery performance and guide resource allocation. Data from community partners, such as Health Care for the Homeless and the Behavioral Health System Baltimore, will be integrated to assess referral follow-through and service utilization. By evaluating these touchpoints, stakeholders can identify patterns in outreach success, client retention, and logistical bottlenecks, allowing them to optimize their strategies. These metrics enable the timely identification of implementation gaps and resource misalignments. Outcome metrics will evaluate the percentage decrease in repeat emergency department visits, self-reported improvements in health and trust in healthcare providers, and increased rates of housing placements. Frontline professionals, such as Ms. Johnson, highlighted the importance of building trust and continuity of care in achieving long-term success with the population. Pre- and post-intervention surveys, along with stakeholder interviews and Community Care Team (CCT) progress notes, will provide qualitative and quantitative insights into client experiences and care continuity. A structured and collaborative evaluation timeline is essential for tracking progress, assessing outcomes, and guiding continuous improvement of the health promotion plan for Baltimore’s homeless population. The evaluation timeframe will include 6-month and 12-month checkpoints for formal analysis, with additional quarterly reports submitted to stakeholders, including the Baltimore Health Department and HUD-funded collaborators. Ongoing stakeholder feedback from clients, nurses, and partner agencies will be crucial in guiding iterative improvements. As emphasized in epidemiological practice, Baral et al. (2020) detail that ongoing surveillance, outcome measurement, and community-informed adjustments are vital to ensuring sustained health equity among homeless populations. The iterative process ensures accountability, responsiveness to community needs, and alignment with evidence-based best practices. Conclusion Addressing health disparities among Baltimore’s homeless population is a critical step toward achieving equity and dignity in public health. The vulnerable group faces compounded risks due to inadequate access to healthcare, mental health services, and hygiene facilities, conditions that demand urgent, targeted responses. Nurses are uniquely positioned to lead the effort through advocacy, direct care, education, and systemic reform, as they serve on the frontlines of both clinical intervention and community engagement. The SMART goals, which aim to increase mobile health access, reduce ER mental health visits, and expand hygiene services, are tailored to the community’s needs and grounded in epidemiological evidence and field observations. Interventions such as peer outreach, mobile clinics, and case management reflect realistic, localized solutions that prioritize both effectiveness and human dignity. Ultimately, sustainable progress requires the integration of data-driven strategies with empathy-cantered nursing practice to foster equity, wellness, and social reintegration.
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