Why target rough sleepers?
Street Health is a service targeting the homeless people of Perth who are rough sleeping and not engaged with any social or medical services in our community. They are found in the parks, public gardens, doorways and pavements of the CBD, and are among the most disenfranchised and marginalised people in our society. Rough sleepers have the worst health outcomes in our state with an average life expectancy of only 45 years.
In 2016 data was collected from a street survey (Perth Registry Week 2016) that assessed 307 rough sleepers in Perth with the validated VI-SDPAT survey tool. The data is sobering. These rough sleepers had been living on the streets for an average of 5 years, duration of homelessness being a key predictor of poor health outcomes. Within the cohort, 42% identified as Aboriginal/TSI, well above the population average of 3.1% in WA. The health of these rough sleepers is poor: 64% have a serious medical condition, 82% have a substance abuse issue and 78% have at least one mental health or cognitive issue while 47% have all three (medical, substance abuse, mental health/cognitive). Despite the high levels of morbidity, only around 25% access GP care. Whilst ¾ have mental health and/or AoD issues, only 3% reported accessing outpatient mental health services and 2% AOD services. More often they wait until late in the course of their illness and present to emergency departments, often requiring prolonged periods of hospitalisation, as reflected in the fact that 47% of the rough sleepers surveyed in 2016 had attended RPH ED, and 18% had been to another Perth Metro Hospital ED.
The rough sleeping population is notoriously difficult to engage because of their high levels of traumatic life experience and previous negative experiences with health services which are not adapted or understanding of their specific needs. Opportunities to intervene early in the course of illness or injury are lost and by the time they reach hospital care, their conditions are serious and require extensive and expensive treatments. As observed at RPH, the street homeless cohort often accesses these services via ED in a pattern of repeated crisis presentations with no continuity of care or early intervention.
Impact of Street Health to date
During the first 18 months of operation, Street Health was able to engage the majority of the rough sleeping population in the Perth CBD, with high levels of acceptance within the group which facilitates engagement with the more reclusive individuals. In the 12 months 2015-2016, Street Health has carried out 929 consultations in 427 rough sleeping individuals. Examples of the care provided include 128 major wound dressings and 81 minor wound care events, 24 diagnoses of diabetes and 17 urgent mental health referrals. During the 2017/2018 period, 18% of Street Health patients decreased their number of hospital days and 62% showed no change in their number of hospital days, indicating that they did not become sicker and spend more of their time in hospital, despite the health risks associated with sleeping rough. The presence of an Assertive Outreach worker on Street Health rounds brings expertise in community services for rehousing and support to public places to start the process of engaging rough sleepers in coming off the street and into accommodation to address the social determinants of health. The coupling of health and community services means that Street Health is able to make a real impact on the lives of rough sleepers, recognising that both issues need to be addressed simultaneously. Thanks to Street Health, many rough sleepers are now regularly attending a general practice and are being rehoused and supported by programs such Street to Home and the 50 Lives 50 Homes collaboration.
How Street Health operates
The Street Health service commenced in January 2015 with start-up funding from the 2014 Impact100 Award. It aims to address this group's lack of access to medical care by engaging rough sleepers where they are, in public spaces, rather than expecting them to present to medical facilities. This is particularly important for Aboriginal people who comprise more than one third of the street homeless in the EMHS area. The Street Health team has consists of a Homeless Healthcare nurse and Assertive Outreach Worker (from Ruah or Uniting Care West) who work in public spaces in the Perth CBD for two hours (usually 7am - 9am) three days per week, on Mondays, Wednesdays and Fridays. As of the 7th of January 2019 a secondary Street Health clinic has been operating in Fremantle, twice a week on Tuesdays and Thursdays. They target places where the rough sleepers congregate such as soup kitchens, parks and malls. Their initial focus is on engagement, gaining trust and encouraging rough sleepers to start using services such as drop in centres and Homeless Healthcare GP clinics. The nurses provide basic medical care on the streets like blood pressure and blood sugar checks, suturing of small lacerations and doing wound dressings. More serious conditions are referred into the weekday morning Homeless Healthcare GP clinics or RPH ED depending on need.