Capella NURS FPX 4055 Assessment 4

Health Promotion Plan Presentation

Greetings! My name is ____________. I am thrilled about today’s session on health promotion for persons experiencing homelessness in Downtown Phoenix. This evaluation emphasizes Carlos Martinez. He is a 42-year-old Hispanic man facing homelessness.  The discussion highlights the social, environmental, and economic factors contributing to homelessness and explores strategies to improve health outcomes. This session aligns with Healthy People 2030 to promote health equity for all individuals, regardless of housing status.

Overview

Homelessness is dangerous to the health and one of the most acute problems in the Downtown Phoenix. Homeless people are prone to chronic illnesses, mental and substance use disorders, as a result of unstable living and inadequate healthcare. According to the 2024 Maricopa Association of Governments, there are more than 9,600 individuals with homelessness in the Maricopa County, and more than half of them are located in central Phoenix (Maricopa Association, 2024). The city of Phoenix is a large and diverse metropolitan region with over 1.6 million people, and its downtown is still characterized by economic and social inequalities and an almost 17% poverty level (DataUSA, 2024).

This health promotion plan focuses on Carlos Martinez who is a 42-year-old Hispanic male who is homeless with chronic illnesses, including hypertension and type 2 diabetes. The intervention will tackle the systemic issues, including low healthcare access, unstable housing, and low health education by using community-based programs, including mobile clinics, culturally sensitive counseling, and peer outreach. These measures are in line with the goals of Healthy People 2030 since they will help achieve health equity, expand access to care among vulnerable groups.

Homelessness in Underserved Urban Populations

Homelessness is a widespread community health issue in Phoenix, Arizona, which is overrepresented among underserved urban areas.  has been on the increase in the city, and the number of the unsheltered population has increased by almost 40 percent between 2024 and 2025. By 2024, Phoenix reported the number of individuals living in uninhabitable places had reduced temporarily by 19% to 2,701 in 2024 than in 2023, but by 2025, over 3,700 people were once again found without stable living conditions, according to the Maricopa Association of Governments (Rummel et al., 2025).

In the Maricopa County, the number of homeless individuals reached more than 9,700 individuals, although this figure is thought to be understated. Carlos Martinez suffers from hypertension, type 2 diabetes, and unpredictable shelter which complicates regular self-care and medication compliance. Among the reasons are the increasing cost of housing, unemployment, mental illness, and poor access to healthcare and social services. To resolve these issues, there must be coordinated, culturally aware interventions, that include provision of accessible care, mental health support and educational outreach. Community health workers and nurses play a crucial role to provide mobile health services, link people to community resources, and support measures to minimize health disparities among homeless (Fritz et al., 2023). 

The Plan Based on Specific, Identified Health Needs and Goals

The target population of the health promotion project is a homeless man Carlos Martinez aged 42 years and living in downtown Phoenix who is of Hispanic origin. He faced barriers include poor housing, inability to access healthcare services, can not cope with chronic illnesses, and severe environmental conditions. Carlos has hypertension, diabetes type 2, and mild depression, and his conditions are complicated with the uneven intake of medicine and the lack of follow-up treatment. These challenges are exacerbated by socioeconomic issues, distrust and mistrust of medical systems (Tol et al., 2025). The intervention will take into account the needs of Carlos and offer individual health education, community-based intervention, and culturally sensitive counseling.

The program will be based on the educational programs related to the management of chronic diseases, hygiene, awareness of mental health, and the resources that can be offered to the community, such as Circle the City and the Human Services Campus. Housing and healthcare programs have been identified to be effective to improve outcomes. Housing First and mobile health clinics, Circle the City help in offering a basic medical treatment (Kaufman et al., 2024). The primary objectives are to help Carlos be more realistic in the self-care plans, refer him to health and social services, and empower him to be active in improving his well-being. The program will respond to the problem of lessening the health disparities amid the homeless individuals in downtown phoenix through the focus on equity, accessibility, and cultural relevance. 

Challenges and Importance of Addressing the Issue

The health promotion of homeless individuals in cities including Downtown Phoenix is a critical issue in improving health within the community and reduces health disparities on chronic illnesses, mental health disorders and premature mortality. Using educational interventions, individuals such as Carlos Martinez, with unstable living conditions, poor health literacy, and inconsistent access to health care can make informed health decisions.

The research indicates that an integrated approach to health education, culturally sensitive counseling, peer support, and access to community outreach enhances health service utilization and physical and mental health outcomes (Gagné et al., 2023). The obstacles taken into consideration include mistrust, stigma, and inaccessibility of the continuity of care. Preventive care awareness, access and solution of systemic problems can be increased through community-based programs, such as mobile health clinics, shelter based programs, and social service partnerships. These efforts align with the Healthy People 2030 goal to promote health equity.

The inability to deal with the health issues related to homelessness has severe implications on the lives of people such as Carlos Martinez. In the absence of specific health promotion programs, the persistent gap of limited access to care, untreated chronic illnesses and poor living conditions result in progressive health decline. This comes with higher risks of cardiovascular diseases, complications of diabetes, infections and low quality of life. The existing data indicate that homeless people with no access to regular care and health education are at a higher risk of uncontrolled chronic diseases, multiple hospital stays, and avoidable mortality (Bensken et al., 2021). Lack of interventions weakens the Healthy People 2030 goals to minimize disparities in health, enhance access to quality care.

Establishing SMART Goals for the Target Group

The SMART model (Specific, Measurable, Achievable, Relevant, and Time-bound) was used to formulate the goals that would help enhance the knowledge and participation of Carlos Martinez in his health management as a homeless person. The educational program was a comprehensive summary of practical ways of controlling hypertension and diabetes, personal hygiene and early signs of complications. It has been shown that a combination of customized health education, peer support, and case management is effective in enhancing disease control and healthcare access among homeless people (Gagné et al., 2023).

The learning processes were presented with the help of simple and culturally relevant materials, interactive discussions, and teach-back techniques to ensure the enhancement of understanding and memory. Nursing personnel helped Carlos to define self-care plans on a daily basis, appointment of follow-up sessions with mobile health services like Circle the City, and communication with peer outreach programs to ensure continuity of care. These interventions will be used to empower Carlos to make sustainable steps to change his health and quality of life of homelessness.

Capella NURS FPX 4055 Assessment 4

The designed SMART goals are:

Goal 1: By the end of the initial session, Carlos will identify and demonstrate three strategies to manage his hypertension and type 2 diabetes daily, including taking medications on schedule, checking his blood pressure, and following a simple dietary plan. Instruction will be supported through culturally appropriate materials, interactive discussions, and teach-back methods to ensure proper application.

Goal 2: Within 30 days of the session, Carlos will visit at least one local clinic or community health service for follow-up care or health screening, schedule necessary appointments for chronic disease management, and identify a plan for maintaining consistent medication adherence that fits his daily routine and living situation.

Goal 3: By the conclusion of the session, Carlos will identify and list at least three community resources for hygiene, mental health support, or substance use counseling available in Downtown Phoenix, and describe how to access these services. Instruction will be reinforced through interactive discussions, teach-back methods, and culturally appropriate materials to ensure understanding and engagement.

Evaluation of Educational Session Outcomes Based on SMART Goals

The success of the health promotion initiative and Carlos Martinez’s progress were assessed based on the established SMART objects. The level of participation in individualized educational sessions served as a primary indicator of engagement. The evaluation included Carlos’s ability to identify and demonstrate daily strategies for managing his hypertension and type 2 diabetes. He understands hygiene practices and preventive health measures.

The evaluation considered follow-up actions, such as visiting local clinics and community health services and utilizing available peer support programs (Fritz et al., 2023). Data collection included self-reports of adherence to disease management strategies, observations by outreach workers, and feedback from community health staff. Integrating these findings with Carlos’s input provided insight into program outcomes, highlighted strengths, and identified areas for future improvement to better support the health of persons experiencing homelessness.

Goal 1: Demonstrating Strategies for Chronic Disease Management

At the end of the education session, Carlos participated in a teach-back activity through guided verbal questioning. He identified and explained three key strategies to manage his hypertension and type 2 diabetes on a daily basis. Taking medications as prescribed, checking his blood pressure, and following a healthy diet are vital. He clarified the applicability of each plan and expressed how these routines avoid complications. This proves health literacy and self-management ability improvement. A community health worker validated the accuracy of his responses and verified that the learning objectives were met. Carlos demonstrated increased confidence in self-managing his conditions, aligning with the first SMART goal. Evidence exists that culturally tailored, pragmatic education improves knowledge and engagement in disease management in homeless persons (Gagné et al., 2023). His presentation showed that interactive methods were clear and relevant, with session outcomes showing an understanding of day-to-day management strategies and their health values.

Goal 2: Engaging with Healthcare Resources

After the educational session, Carlos established that he had scheduled a visit to a local clinic and community health service for follow-up care within the next 30 days. He contributed in a guided planning exercise for attending the appointment. This includes arranging transportation, preparing questions for healthcare providers and organizing his medications and health records. Strategies are made to maintain medication adherence and methods to track his chronic disease management at home. He reviewed the plan with the outreach worker, who confirmed that it aligned with current practices for improving engagement in healthcare among homeless populations (Fritz et al., 2023). Carlos demonstrated increased confidence in accessing services, managing his health needs, and adhering to recommended treatment plans. The successful completion of this planning exercise validated the intervention’s success.

Goal 3: Engagement with Community Resources

During the follow-up evaluation, Carlos confirmed that he had identified and connected with at least three community resources for hygiene, mental health support, or substance use counseling available in Downtown Phoenix. He reported visiting one of the local shelters’ resource centers and participating in a peer outreach session, documenting his experiences and insights in a self-monitoring log. These activities focused on accessing health services, maintaining hygiene, managing stress, and utilizing mental health and substance use support. Structured support from community workers and peers emerged as a key facilitator for engagement, enhancing his confidence in navigating available resources. Evidence suggests that combining culturally responsive education with social and community support improves health outcomes among homeless populations (Franco et al., 2021). Carlos’s active participation demonstrated that the intervention connected him with services.

Need for Revisions

The efficiency of future instructional approaches enhanced by culturally responsive learning setting that can meet the needs of participants such as Carlos Martinez. During his feedback, Carlos expressed an inability to understand complicated descriptions of how to manage his chronic conditions and access to community resources. This highlights the significance of simplification of language, clear instructions, and content to fit the health literacy of the target audience. The incorporation of interactive learning opportunities include blood pressure monitoring use visual instructions, dietary demonstrations, and brief educational videos on the management of chronic diseases, may be used to reinforce the understanding and retention.

It has been found that visual and experiential learning boosts biomedical knowledge and promotes practical self-management skills in underserved populations (Kaufman et al., 2024). As Carlos mentioned, he had trouble locating available services and knowing how to access them, so guided resource navigation and problem solving in scenarios were the applied learning activities that he had to implement. The practical elements will be included in the future sessions to improve the health literacy of the participants so that they can make informed decisions in terms of chronic disease management, hygiene, and the use of social support. Respondents noted the importance of protracted discussion and Q&A and proposed that further discussion opportunities can enhance trust, interest, and long-term compliance with health-promoting behaviors. Expanding access to culturally relevant resources based on the needs of the homeless population can be used to increase coverage.

Healthy People 2030, Objectives and Leading Health Indicators

The assessment of the health promotion program results on Carlos Martinez based on the Healthy People 2030 objectives gave important information on the effectiveness of the program. The intervention proved to have quantifiable advances into better management of chronic diseases, better involvement in healthcare services, and better housing (Healthy People 2030, 2020). At the close of the program, Carlos showed greater confidence and skills to recognize and apply the daily strategies to cope with his chronic illnesses, such as medication, blood pressure, and dietary changes. In 30 days, he managed to visit a local clinic to receive follow-up care and refer to community resources related to hygiene, mental health support, and substance use counseling.

His involvement in peer-based and outreach programs strengthened his motivation, self-efficacy, and sustained involvement in health-promoting behaviors. The teaching methods, such as plain-language teaching, culturally related texts, direct demonstrations, and guided discussion, reinforced what Carlos learned and his involvement in the program. The results are in line with the priorities of Healthy People 2030 and highlight the significance of community-based interventions that are equitable and will decrease health disparities and enhance wellness among homeless urban populations (Healthy People 2030, 2020). The success of the program underscores the development of bettering the health of Carlos in addition to the general population health to help the homeless people to attain long-term health.

Need for Revision for Better Alignment with Healthy People 2030

The significance of revisions is in enhancing health promotion sessions in the future, which should consider the obstacles encountered by the participants such as Carlos Martinez and need to align with the objectives of Healthy People 2030. Carlos met a number of goals in the first session, reported that he struggled to grasp complicated instructions regarding chronic condition management, availing community services, and negotiating health care services. This highlights the necessity to make technical terminology less complex and contextualize information.

Structured group discussions, scenario-based activities, and short knowledge-assessment exercises are examples of interactive strategies that can be used to increase the level of understanding, confidence, and health literacy. The educational material must be in simple language and that should be complemented by visual aids that are culturally familiar to the experiences of homeless people. Experiential experiences, including a tour of the local clinics, demonstrations of blood pressure monitoring and social service resources navigation, are essential for improving health literacy skills (Bensken et al., 2021). Community-based sessions are crucial to the achievement of behavioral change, engagement, and Healthy People 2030 goals to enhance health equity among underserved urban populations.

Conclusion

The strategy underlines the paramount need to deal with the complex problems that homeless people are exposed to. The program showed changes in the management of chronic diseases, health literacy, and access to healthcare services through culturally competent education. It includes the growth of practical skills and community resource connections. The importance of community-based and culturally sensitive plans in improving the health and flexibility of homeless individuals is emphasized in this agenda.

References

Bensken, W. P., Krieger, N. I., Berg, K. A., Einstadter, D., Dalton, J. E., & Perzynski, A. T. (2021). Health status and chronic disease burden of the homeless population: An analysis of two decades of multi-institutional electronic medical records. Journal of Health Care for the Poor and Underserved, 32(3), 1619–1634. https://doi.org/10.1353/hpu.2021.0153

DataUSA. (2024). Phoenix, AZ | Data USA. Datausa.io. https://datausa.io/profile/geo/phoenix-az/ 

Franco, A., Meldrum, J., & Ngaruiya, C. (2021). Identifying homeless population needs in the emergency department using community-based participatory research. BioMed Central Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06426-z

Capella NURS FPX 4055 Assessment 4

Fritz, C. K., Khan, J., Kontoyiannis, P. D., Cao, E. M., Lawrence, A., & Love, L. A. (2023). Analysis of a community health screening program and the factors affecting access to care. Cureus, 15(7). https://doi.org/10.7759/cureus.41907 

Gagné, E. P., Jacques, M.-C., Legault, P. P., Ahmed, B., & Stroe, I. R. (2023). The perspectives of homeless people using the services of a mobile health clinic in relation to their health needs: A qualitative study on community-based outreach nursing. Journal of Research in Nursing, 28(2), 154–167. https://doi.org/10.1177/17449871231159595 

Healthy People 2030. (2020). Housing and homes – Healthy People 2030. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/housing-and-homes

Kaufman, R. A., Mallick, M., Louis, J. T., Williams, M., & Oriol, N. (2024). The role of street medicine and mobile clinics for persons experiencing homelessness: A scoping review. International Journal of Environmental Research and Public Health, 21(6), 760–760. https://doi.org/10.3390/ijerph21060760

Maricopa Association. (2024). Homelessness trends – report Maricopa County Regional. https://azmag.gov/Programs/Homelessness/Data/Homelessness-Trends 

Rummel, H., Young, L. D., Raymundo, S., & Reagor, C. (2025, October 20). Why homelessness may be a bigger challenge now than in days of “The Zone.” https://eu.azcentral.com/story/news/local/phoenix/2025/10/20/phoenix-homelessness-grows-worse-since-the-zone/84247801007/

Tol, Z. V., Middel, A., Vanos, J. K., & Ferguson, K. M. (2025). Overexposed and understudied: Environmental risks among older adults experiencing homelessness in Phoenix, Arizona. GeoHealth, 9(5). https://doi.org/10.1029/2025gh001372