UNIVERSITY OF WASHINGTON Improved Patient Outcomes Meeting the needs of homeless patients with overutilization of the ED Jacquelyn M. Pinkerton 3/12/2015 People who are homeless have to depend on a variety of emergency services to meet their needs which has created a vicious cycle of service utilization that is difficult to break. Being homeless can create a constant state of crisis; this state of crisis is perpetuated by not being able to meet basic needs, feelings of isolation, feelings of fear, as well as compounding loss of social connections, job, and health (Clarke, Williams, Percy, & Kim, 1995). Current health systems lack services designed to meet the needs and complexity of homeless persons and this inadequacy enables the use of the emergency room as these peoples’ needs continue to go unmet (Parker & Dykema, 2013). The research indicates a need for better interpersonal, interdepartmental, and interagency collaboration to do more to increase efficacy of initial interventions and improved preventative measures to reduce unnecessary readmissions.
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University of Washington
Improved Patient Outcomes
Meeting the needs of homeless patients with overutilization of the ED
Jacquelyn M. Pinkerton
3/12/2015
People who are homeless have to depend on a variety of emergency services to meet their needs which has created a vicious cycle of service utilization that is difficult to break. Being homeless can create a constant state of crisis; this state of crisis is perpetuated by not being able to meet basic needs, feelings of isolation, feelings of fear, as well as compounding loss of social connections, job, and health (Clarke, Williams, Percy, & Kim, 1995). Current health systems lack services designed to meet the needs and complexity of homeless persons and this inadequacy enables the use of the emergency room as these peoples’ needs continue to go unmet (Parker & Dykema, 2013). The research indicates a need for better interpersonal, interdepartmental, and interagency collaboration to do more to increase efficacy of initial interventions and improved preventative measures to reduce unnecessary readmissions.
Pinkerton: Improved Patient Outcomes
Jacquelyn Pinkerton
Improved outcomes for homeless patients who use the ED to meet their basic needs
Logic Model Template...................................................................................................................................9
Data Collection Worksheet..........................................................................................................................10
Description of Project..................................................................................................................................12
Problem Map................................................................................................................................................21
Force Field Analysis....................................................................................................................................22
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IntroductionI am proposing a designated position, within the hospital setting, that aims to meet the
needs of our most vulnerable patient population, namely homeless patients with high-utilization
of Emergency Department (ED) services. The short term goals are to improve patient knowledge
of community resources and improve patient access to these community resources. Looking to
the future, the long-term goal of this position is to eliminate the use of the ED by homeless
patients to meet their basic needs (eg. food, shelter, clothing, transportation etc.). These goals
necessitate that ED systems engage in interagency and interdepartmental collaborations to
connect homeless patients to providers who can meet their basic needs as evidenced by decrease
use of the emergency department. The characteristics of this proposed position include
acknowledging the dignity and worth of a person, cultivating human relationships, behaving in a
trustworthy manner, and providing services that are socially just (Martin, 2014; Parker &
Dykema, 2013; Reitz-Pustejovsky, 2002). It is important to provide real time referrals and
interventions specific to the individual being served as this approach is more effective and aligns
with NASW and agency ethical principles (Parker & Dykema, 2013).
NASW guidelines and Citizenship theory are the guiding framework for meeting the
needs of homeless patient’s utilizing the ED for non-emergencies. For these patients who are our
most vulnerable, an effective intervention must consider a theoretical framework that addresses
the relationship between justice and attachment; interventions must be meaningful for those
receiving care more than being for the person or agency offering care (Reitz-Pustejovsky, 2002).
Citizenship theory incorporates both justice and attachment by looking at the individual within
the community and whether they are represented and treated as citizens rather than being
relegated as an ‘other’. ‘Just’ care cannot be done without promoting attachment between
marginalized people and the mainstream community of which they are a part (Reitz-Pustejovsky,
2002). Citizenship theory emphasizes the agency of the individual and values the dynamic
between individual and community; when people are pushed further away from being a part of a
community they are treated as less than full citizens and subjected to subsequent injustices.
Sanabria (2006) applies attachment theory as it relates to an individual’s attachment to their
community and suggests if there is poor attachment then there are associated risks including a
minimized sense of belonging, poor outcomes for public health and increased rates of violence
and poverty. Citizenship theory reframes the conversation around homelessness by valuing the
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Pinkerton: Improved Patient Outcomes
individual members’ and their potential contributions to society and opens the conversation to
the opportunity of community building to address a social issue (Reitz-Pustejovsky, 2002).
Finally, citizenship theory also provides a framework for treating within a psycho-social context
(Rowe, Kloos, Chinman, Davidson, & Cross, 2001). By operating within this framework we will
address the strengths and needs of the individual while collaborating with the larger community
to improve outcomes.
By implementing a designated position to facilitate continuity of care following ED
discharge, the anticipated outcomes include improved patient knowledge of community
resources and improved patient access to services. An assumption of this proposal is that
homeless patients are brought to the ED, voluntarily or involuntarily, because they have basic
needs that are not being met in the community. By utilizing the designated case worker in real
time we can identify the most emergent needs and actively implement referrals rather than
provide patients with a handful of generic resources and send them on their way. In addition to
the direct services provided to patients, this position must also cultivate and maintain community
partnerships to ensure a smooth transition for referrals. When providers collaborate, rather than
operate siloed within their agency, they can more effectively meet the needs of the patient by
mitigating the risk of losing them in the transition and also by reducing inefficiencies of
duplicative work inherent in repeat data collection. In addition to the individual patient outcomes
this intervention will also free up ED beds, provide cost savings to the hospital by reducing
readmission of patients whose services may not be reimbursable, and improve relationships with
community partners who can meet the needs of these patients in an outpatient community
setting.
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Proposed assessment tool: Initial Encounter in EDEncounter Date: Record the date of first encounter with patient
Patient Name: Lat name, First Name Patient Number: System generated patient ID #
Means of Arrival: Indicate how the patient arrived in the ED at current encounter. Consider looking at previous ED admissions and patient means of arrival, this may inform subsequent intervention as it relates to barriers and indicated (in)voluntary use of ED.
Presenting Problem: Record the presenting problem upon arrival.
Secondary Problem(s): Ask the patient if there are additional problems not addressed in previous section.
Patient Goals for Treatment: What are the patient’s treatment or outcome goals. Is the patient amenable to service/intervention?
Needs or Barriers: Indicate patient self-reported needs or barriers preventing access to services or treatment. Case Worker can infer additional items but should validate with patient for accuracy.
Mental Health Services
Case Management Counseling Rx Management
Medication Prescriber Access Coverage Management
Food Food Stamps Local Food Banks Hot Meal providers
Shelter Case Management Physical Shelter
Transportation Bus Pass Taxi Scrips Gas Card
Communication Telephone Voicemail Email Mailing Address
Storage
Other, specify
Strengths and Informal Supports: Identify patient strengths and informal supports available to meet identified goals.
Case Manager
Family, friends
Spiritual Congregation
Community Group
Support Group
Other, specify
Next Steps: What are the next steps within the 1st week of encounter. How will Case Worker and patient reconnect?
Subsequent EncountersWithin 7 days of initial ED Encounter.
Review Initial Assessment Make adjustments to action plan and implement identified next steps.
Implement action plan within first 30days. Ensure that patient has made connections with community service providers or identified case managers.
Follow-up with patient at 3/6/12 month intervals to monitor progress and facilitate ongoing implementation of plan. Make changes to the plan as needed based on patient’s changing psycho-social context, survey responses, and 1:1 interview.
Administer survey prior to face to face and discuss during appointment.
1. What are your needs (for example: shelter, food, personal hygiene, clothing, storage, telephone/internet, transportation, medical follow-up, dental, counseling, employment services, case management)
a. _____________b. _____________c. _____________
2. Where can you go to meet the needs you listed?a. _____________b. _____________c. _____________
3. Who can you contact to attain resources?a. _____________b. _____________
4. Who can help you attain community resources if you are unable to access them independently? ____________________________________________________________________________
Interview: Review action plan established at initial intake. Discuss patient gaps in knowledge about their individual action plan. Ask patient if their needs are being met.
Case Records: Review hospital EDIE report and patient encounter record. Discuss outcomes or record with patient during interview.
1. Made necessary appointment (indicate type of services):a. Service __________________Appointment Date _______________ Attended/Missed
i. Reason missed(if applicable) _________________________________________b. Service __________________Appointment Date _______________ Attended/Missed
ii. Reason missed(if applicable) _________________________________________c. Service __________________Appointment Date _______________ Attended/Missed
iii. Reason missed(if applicable) _________________________________________
Pinkerton: Improved Patient Outcomes
Supplemental ActivitiesEstablish and maintain Memorandums of Understanding (MOUs) with community partners. MOUs to be established with community providers who provide services relevant to our target population.
Work with IT Specialist to improve resource database; monitor accuracy of database on a monthly basis to ensure efficient referrals.
Meet with community partners quarterly to discuss what is working in the referral process and identify areas for improvement.
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Logic Model TemplateNeeds Statement: ED systems need to engage in inter-agency/interdepartmental collaborations to connect homeless patients to providers who can meet their basic needs as evidenced by decrease use of the emergency department.Theoretical Influences and Assumptions: Citizenship theory is the guiding framework for meeting the needs of homeless patient’s utilizing the ED for non-emergencies. This theory emphasizes the agency of the individual and values the dynamic between individual and community. By operating within this framework we will address the strengths and needs of the individual while collaborating with the larger community.
RESOURCES
ACTIVITIES
(Process Objectives)
OUTPUTS*
(Outcome/Summative Objectives)
OUTCOMES
(Short term goals)
*OUTCOME
INDICATORS (Outcome/Summative
Objectives)
LONG TERM GOAL
Funding for new
position Funds to invest
in possible community placement or referral settings (designated beds or one night stays)
Agency vehicle to provide client transportation or mileage reimbursement
Tech support and updated resource list
Create
Memorandums Of Understanding (MOU) with partner agencies
Maintain partnerships with MOU’s
Develop initial process with case worker for referral
Case worker ensures follow-up with community agency
Hospital designated case worker
Improved database with map of community resources
MOU’s with
shelter/food/resource providers within the Auburn community
Quarterly roundtable with partners to address service referral issues
Increase meeting of patient’s basic needs through effective referral process and action plan
Free up ED beds Online interactive
resource map
Outcome 1: Improved knowledge of community resources.
Outcome indicator 1a: Knows who to contact to attain community resources. Outcome indicator 1b: Knows how to get community resources.
The long-term goal is to eliminate the use of the Emergency Department by homeless patients to meet their basic needs (eg. Food, shelter, clothing, transportation etc.)
Outcome 2: Improved access to services
Outcome indicator 2a: Accesses services that meet needs. Outcome indicator 2b: Implements action plan to meet service needs with other community resources.
Pinkerton: Improved Patient Outcomes
Data Collection Worksheet
OUTCOMES/CRITERIA TOOLSDATA
COLLECTION PROCESS
DATA COLLECTION
METHODVALIDITY
Outcome 1: Improved knowledge of community resources. Criteria: Patient has achieved outcome indicators 1a and 1b. Outcome indicator 1a: Knows who to contact to attain community resources. Criteria: Patient can identify their needs and appropriate resources to meet those needs on a survey. Outcome indicator 1b: Knows how to get community resources. Criteria: Patient is able to indicate on the survey how to access services to meet their basic needs.
Outcome 1 Tool:Survey: Objective measurement of whether patient possesses the knowledge that indicates progress or competence.
Collected at initial appointment and final appointment.
Gather data on all clients.
Peers and key stakeholders are able to identify the purpose of the questions being asked
Participants respond appropriately
Participants consistently respond appropriately
Data supports participant responses
Outcome 2: Improved access to services. Criteria: Patient has achieved outcome indicators 2a and 2b.Outcome indicator 2a: Accesses services that meet needs. Criteria: Patient is able to self-report where there needs have been met and there will be a decreased incidence of ED utilization.Outcome indicator 2b: Implements action plan to meet service needs with other community resources. Criteria: During interview patient can articulate the action plan and whether that plan has led to their basic needs being met.
Outcome 2 Tool: Interview with patients: Their subjective understanding of behavior competence. Case Records: Objective tool to evaluate patient’s previous use of inappropriate services compared to current use of appropriate services.
Case worker collects this information at final appointment and then 3/6/12 month follow-up intervals.
Check ED reports. Provide case worker contact information to patients and encourage patient to
RELIABILITY
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Pinkerton: Improved Patient Outcomes
Outcome 1: Improved knowledge of community resources. Outcome indicator 1a: Knows who to contact to attain community resources. Criteria: Patient can identify their needs and appropriate resources to meet those needs on a survey. Outcome indicator 1b: Knows how to get community resources. Criteria: Patient is able to indicate on the survey how to access services to meet their basic needs.
Survey (administer survey prior to face to face and discuss during appointment)
5. What are your needs (for example: shelter, food, personal hygiene, clothing, storage, telephone/internet, transportation, medical follow-up, dental, counseling, employment services, case management)
a. _____________b. _____________c. _____________
6. Where can you go to meet the needs you listed?a. _____________b. _____________c. _____________
7. Who can you contact to attain resources?a. _____________b. _____________
8. Who can help you attain community resources if you are unable to access them independently? ____________________________________________________________________________
Outcome 2: Improved access to services. Outcome indicator 2a: Accesses services that meet needs. Criteria: Patient is able to self-report where there needs have been met and there will be a decreased incidence of ED utilization. Outcome indicator 2b: Implements action plan to meet service needs with other community resources. Criteria: During interview patient can articulate the action plan and whether that plan has led to their basic needs being met.
Interview: Review action plan established at initial intake. Discuss patient gaps in knowledge about their individual action plan. Ask patient if their needs are being met.
Case Records: Review hospital EDIE report and patient encounter record. Discuss outcomes or record with patient during interview.
2. Made necessary appointment (indicate type of services):a. Service __________________Appointment Date _______________ Attended/Missed
iv. Reason missed(if applicable) _________________________________________b. Service __________________Appointment Date _______________ Attended/Missed
v. Reason missed(if applicable) _________________________________________c. Service __________________Appointment Date _______________ Attended/Missed
vi. Reason missed(if applicable) _________________________________________
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Pinkerton: Improved Patient Outcomes
Description of ProjectThe following proposal is a micro-level intervention aimed at serving homeless
patients who over utilize the hospital Emergency Department (ED) to meet their basic needs.
This intervention requires a designated case worker who can meet patients where they are at,
conduct a holistic psycho-social assessment to identify their strengths and needs, develop an
individual action plan, connect these patients with providers in our community for ongoing
support, and provide follow-up to ensure successful implementation of their individual action
plans. Not only will this proposed intervention improve outcomes for the patients being
served but it will reduce fiscal losses incurred by the hospital for rendering services that may
or may not be reimbursed. Over-utilization of the ED by patients, specifically homeless
patients, requires an intervention that connects the individual to the larger community in
order to break the cycle of: ED utilization for immediate crisis relief, rapid discharge, and
subsequent return to the ED.
Our target population consists of those patients who are repeatedly admitted to the
ED because their basic needs are not being met in the community. Basic needs may include
shelter, food, security, stability, medical, and/or mental health treatment. Some of these
patients come to the ED voluntarily while others are brought to the ED involuntarily. For
these patients who are our most vulnerable, an effective intervention must consider a
theoretical framework that addresses the relationship between justice and attachment.
Interventions must be meaningful for those receiving care more than being for the person or
agency offering care (Reitz-Pustejovsky, 2002). Citizenship theory incorporates both justice
and attachment by looking at the individual within the community and whether they are
represented and treated as citizens rather than being relegated as an ‘other’. ‘Just’ care cannot
be done without promoting attachment between marginalized people and the mainstream
community of which they are a part (Reitz-Pustejovsky, 2002). Citizenship theory
emphasizes the agency of the individual and values the dynamic between individual and
community; when people are pushed further away from being a part of a community they are
treated as less than full citizens and subjected to subsequent injustices. When trying to meet
the needs of those being served it is unjust to leave them out of the conversation because they
do not have the economic privilege to interject themselves into the conversation (Sanabria,
2006). Sanabria (2006) applies attachment theory as it relates to an individual’s attachment to
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Pinkerton: Improved Patient Outcomes
their community and suggests if there is poor attachment then there are associated risks
including a minimized sense of belonging, poor outcomes for public health and increased
rates of violence and poverty. Citizenship theory reframes the conversation around
homelessness by valuing the individual members’ and their potential contributions to society
and opens the conversation to the opportunity of community building to address a social
issue (Reitz-Pustejovsky, 2002). Finally, citizenship theory can also provide a framework for
treating within a psycho-social context (Rowe, Kloos, Chinman, Davidson, & Cross, 2001).
I propose that we allocate resources for a designated case worker to meet the
individual needs of our target population that allows for continuity of care following
discharge therefore improving outcomes and reducing overall costs to the hospital. This case
worker would have improved access to resource database information and be responsible for
maintaining memorandums of understanding (MOU’s) with partner agencies to facilitate
implementation of patient’s individual action plans. Anticipated outcomes of this
intervention include better outcomes for our patients, freeing up ED beds, and cost savings to
the hospital by reducing readmission of patients whose services may not be reimbursable. We
will also have improved relationships with community partners who can meet the needs of
these patients outside the scope of services available in the ED.
Values and ethical considerations guiding this intervention include acknowledging
the dignity and worth of a person, cultivating human relationships, behaving in a trustworthy
manner, and providing services that are socially just (Martin, 2014; Parker & Dykema, 2013;
Reitz-Pustejovsky, 2002). It is important to provide real time referrals and interventions
specific to the individual being served as this approach is more effective and aligns with
NASW and agency ethical principles (Parker & Dykema, 2013).
BackgroundThe needs identified to address the problem of overutilization of the ED for non-
emergencies include needed resources and changes in ED practice. Resources that are needed
include tools for service providers to more efficiently identify/organize what is available to
meet patients’ needs within the context of their own limitations. Hospital organizations could
utilize fiscal resources to reserve crisis beds and/or fund community shelters to increase
capacity in the community and decrease reliance on ED beds. Without necessarily putting
money directly into the community, organizations may benefit from having a staff person
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Pinkerton: Improved Patient Outcomes
who specializes in knowing what resources are available and maintaining MOUs with those
providers. There is a need for someone to be available outside of normal business hours to
implement intervention and prevention strategies for ED high-utilizers. This designated role
could address emergency and long-term intervention needs for the including care
coordination, supporting those most at risk, and strengthening relationships between agencies
(Kutza & Keigher, 1991). Outreach is important component to meet the needs of a population
that faces barriers as ‘simple’ as a front door (Martin, 2014; McDougal-Treacy, 2014).
Finally, there is a need to break down the barriers that lead to providers working within
individual silos thus reducing the efficacy of care and collaboration. Applebee (2014)
discussed the challenges of effective intervention in the emergency rooms because medical
staffs have a priority to meet the emergency medical needs of patients and this requires that
referrals be made to other ED staff for ongoing follow-up or intervention. While it makes
sense that medical staffs do not have the time to do individual intervention there is room for
improvement as far as collaboration between roles and effectively meeting the patients’
needs. Increased collaboration in connecting homeless patients with community providers is
a potential need due to a common misperception that homeless people are especially mobile
and not likely to follow-up with outpatient care (Parker & Dykema, 2013).
Homelessness is not a new issue and it impacts readmission rates within emergency
departments by the chronically ill and mentally ill due to an ongoing lack of adequate
community supports and shelter (Rosenfield, 1991). Homelessness has and continues to
evolve based on changing social and economic climate. For example, in the 1980’s there was
a social and political shift that resulted from unintended consequences of
deinstitutionalization of the mentally ill, ‘War on Poverty’, and establishment of minimum
wage (Clarke, Williams, Percy, & Kim, 1995). These social policy changes were designed to
reintegrate the mentally ill into the community, establish a safety net, and combat a social
issue that had a resurgence of public visibility and attention. Deinstitutionalization was
especially detrimental in that it took away basic needs like shelter, regularly scheduled meals,
accessible mental health and medical providers, and stability without creating community
supports to provide continuing care (Kutza & Feigher, 1991; Rosenfield, 1991). Socially
there is a general consensus that the issue of homelessness requires intervention but as a
collective we lack the conviction to hold ourselves accountable to meeting this need.
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Pinkerton: Improved Patient Outcomes
Homeless people are a vulnerable population and those with the social and political power
have a responsibility to advocate for justice on behalf of those without power (Reitz-
Pustejovsky, 2002). In addition to our social responsibility to address the problem of
homelessness we also need to change our attitudes towards the homeless population. We
create artificial standards for those who are deserving of help, like veterans, women and
children, and those who are undeserving like men, immigrants, and drug addicts; these
artificial lines blur our vision and treatment of these people and create unnecessary hurdles in
trying to initiate change. Trying to judge those deemed unworthy and mandating that they
change their individual behaviors isolates them from mainstream society thus perpetuating
stigma and a cycle of victim blaming (Laakso, 2013).
Regardless of the time period, some similarities identified in the past and present
homeless populations include extreme poverty, mental illness and/or chemical dependency,
physical disability, social isolation, and reliance on shelters, food banks, community health
clinics, and clothing banks to meet their basic needs (Rossi, 1990). This population has to
depend on a variety of emergency services to meet their needs and it has created a vicious
cycle of service utilization that is difficult to break. Being homeless can create a constant
state of crisis as individuals are unable to cope as a result not knowing how they are going to
meet their most basic needs, feelings of isolation, feelings of fear, as well as compounding
loss of social connections, job, and health (Clarke, Williams, Percy, & Kim, 1995).
Homelessness is perpetuated by a culmination of relatively ‘minor’ setbacks that reinforce an
individuals’ need to ‘just’ survive not allowing them to ever get ahead (Clarke, Williams,
Percy, & Kim, 1995). Socially we need to support these people and implement a system that
facilitates real change rather than ad-hoc or short-term temporary fixes.
Contributing research interventions presently identified in the literature include
psychosocial assessments to determine individual needs, outreach teams to address barriers to
care compliance, reducing barriers faced by homeless patients, utilizing outpatient referral
resources, improved continuity of care, and involving the community. Conducting a needs
assessment is important within micro level interventions as it will inform subsequent
intervention and supports the value of meeting each person where they are and not
compromising that interaction by trying to pull them out of their context and imposing
dominant ideas of what is best (Kutza & Keigher, 1991). Outreach teams can also reduce
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Pinkerton: Improved Patient Outcomes
barriers faced by homeless patients’ as it relates to transportation needs or forcing them to
prioritize preventative care and meeting their basic needs for survival (McDougal-Treacy,
2014). Sanabria (2006) discusses how lack of coordination can make subsequent
interventions ineffective. Rosenfield (1991) also discusses ongoing contact and continuity of
care positively impacting patient outcomes by reducing utilization of the emergency room for
non-emergencies. Parker and Dykema (2013) found in their research that providers who
practiced active referrals to outpatient sources saw better outcomes, for example reduced
emergency room visits, than providers who discharged patients with directions along the idea
of ‘If symptoms get worse come back.’. For those who are homeless they face social barriers
that perpetuate marginalization and make it more difficult to improve their situation (Laakso,
2013). Martin (2014) suggests that service providers can better serve this population by
reducing burnout among providers so they can provide a good experience to service
recipients that encourages them to seek help, reducing material barriers or help people
overcome material barriers such as requirement of identification or a mailing address, value
individuals’ need for self-efficacy and self-esteem, and build human relationships that reduce
the separation of patient and professional. Assertive Community Treatment (ACT) teams are
another possible intervention that was mentioned in the literature as possibly effective
intervention. ACT teams have been found to reduce the negative impact of staff turnover,
thus supporting continuity of care, and may address the challenges associated with care non-
compliance as a result of choice or addressing barriers to full participation (Bond, et al.,
1991; Rowe, Kloos, Chinman, Davidson, & Cross, 2001). ACT teams work from a strengths
based perspective, address patient identified needs, and provide a stable foundation for