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.
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. Over the last 18 months, Street Health team has consisted 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 three hours (usually 6am – 9am) five days per week. 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.
Impact of Street Health to date
During the first 18 months of operation, Street Health engaged with 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. 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.
Case study 1
Background: Howard is a 40 year old Aboriginal man who has experienced nearly 15 years of street homelessness. He has a complex history of alcohol abuse and trauma, and has had many interactions with the health and justice systems including prison time. In 2016, Howard had a VI-SPDAT score of 14.
Interactions with Street Health and impact on health outcomes
Howard has had frequent contact with Homeless Healthcare since 2014, most often seen by Street Health. Alcohol dependence, drug use, mental health and wound infections are among the health issues he has presented with. In early 2017 he had a serious laceration and abscess. Dr Amanda Stafford of the RPH Homeless Team commented “Howard’s abscess was a good pick up by Street Health – it was a nasty abscess on his arm and he needed to be sent back to RPH ED multiple times by Street Health to get this healed.” Homeless Healthcare saw him while he was in hospital and Street Health provided wound care and dressing changes in the community.
Street Health has been active in encouraging Howard to address his alcohol dependence, including referral suggestions to rehab programs and advice on pharmacological treatment options. Around the time of the abscess, Howard was intermittently residing in crisis accommodation, and the Homeless Healthcare nurses continued to have contact with Howard with him there. As recounted by one HHC nurse, HHC assisted him to stabilise his alcoholism and manage cravings with Baclofen, and patiently worked with Howard when he wanted to stop the treatment:
“He had some misconceptions about the medication, and was strongly externalising… blaming the medication erroneously for all manner of his misfortunes (like being convicted of drink driving) and was adamant that he was going to stop taking them. From my time working with drug and alcohol dependence, I’m convinced that Baclofen works, and really wanted him to give it a chance. I heard him out, allowing him to vent his frustration and express himself. Then came time to challenge him a little. We essentially began the education process again, challenging his externalising of blame, and misconceptions and engaging in some motivational interviewing that culminated in him agreeing to continue the medication, and actually increase the dose (it needs to be titrated up slowly over weeks, to a therapeutic dose).”
Howard is now residing in transitional accommodation, which as noted by a HHC nurse:
“is in itself is a great marker of success as maintaining tenancy, even in supported accommodation is a significant step for someone with such substance misuse and mental health problems.”
Impact on healthcare used and costs to date: Between January 2015 and June 2017, Howard presented to ED 20 times and had 9 non-psychiatric admissions (total 20 days LOS). During this time he had a total estimated cost associated with health services use of $61, 420. In the six months following, he had no ED presentations or admissions.
Case study 2
Background: Chris is a 48 year old man who has been homeless for around 9 years. In 2014 he scored 10 on the VI-SPDAT survey and reported having comorbidities of mental health and alcohol and drug issues. During 2017, Chris had multiple ED presentations relating to a cyst on his hip that was repeatedly infected over a two month period.
Interactions with Street Health and impact on health outcomes
Chris has been known to Street Health since 2013. In April 2017, he approached Street Health with a 10cm abscess, and Street Health transported him to Royal Perth Hospital for abscess draining and dressing. He returned to ED on 4 occasions for dressing changes in the days following the initial drainage at the hospital. The average ED visit in a Perth public hospital is costed as $656, equating to an estimated cost of $2624 for dressing changes in the ED setting. He subsequently saw the Street Health nurses 9 times over the next month to have his abscess wound dressed. As observed by Dr Amanda Stafford of the RPH Homeless Team, “It has taken 6 weeks of dressings by Street Health and the wound has now completely healed”.
Having his wound re-dressed by Street Health cost substantially less, with an average consult with the Street Health team costing $37 (compared with the cost of $656 for an ED presentation). Hence 9 visits with the Street Health nurse for his dressing changes totaled only $333, compared with a cost of $9184 to the health system if he had presented at ED on these 9 occasions.
Case study 3
Background: Daisy is a 25 year old Aboriginal woman who has been largely homeless for a decades, after running away from foster care at age 15.
“ I was a ward of the state. Grew up in DCP care. I just kept running away all the time and I didn’t like rules and stuff. They were very strict but I didn’t like it. Because I got split up from my brothers and sisters because I kept trying to run away to find them. I just ended up – I just liked the street life. I didn’t like it, at the time I liked it because I had all my friends on the street. It was just easier. But then I got accustomed to it. Then it got harder and harder as time, because then I started. Those friends I had, I lost. Then there was too much drugs and yeah. It was pretty hard road.”
In 2016 Daisy scored 15 on the VI-SPDAT survey, which also indicated a history of alcohol and intravenous drug abuse and mental health problems.
“It’s hard on your own, but you have to – when you sleep you’ve got to keep one eye open. It’s hard to fall asleep because you’re always worrying about what’s going to happen and stuff. That’s why I turned to drugs a little bit, to keep me alert and stuff.”
Daisy suffers from a number of serious medical conditions, including Type 2 diabetes, liver disease, Hepatitis C and asthma. Her diabetes has been particularly exacerbated by life on the streets.
“Because I’ve got diabetes, and my sugars have been real high lately. That’s why getting a house was very important because of my health. Deteriorating health. Because I’m not on top of it. Because being on the streets and stuff is hard. But having my insulin, not being in the fridge. Just keeping on top of my medications and all that, it was pretty hard.“
Interactions with Street Health and impact on health outcomes
Daisy first interacted with Street Health in April 2017. Since then she has seen them 30 times, mostly for blood sugar tests and psychological support. In her own words:
“without homeless healthcare I reckon I’d be dead”
“The nurses are awesome. There’s a program in the morning, the Salvos, they come to the park here and the nurse comes with them. You can get a check-up, I can get my sugar taken. They have things like toiletries and stuff. You have a cup of tea and they just talk to you and stuff.”
Daisy was provided with transitional housing during 2017 as part of the 50 Lives 50 Homes program, and continued to receive assistance from the Homeless Healthcare After Hours team. Unfortunately, a return to drug use and a complex domestic violence situation led to loss of this accommodation, and she has returned to living on the street. Daisy continues to visit the Street Health van frequently since she has resumed rough sleeping. Homeless Healthcare has significant concerns about the poor management of her diabetes due to homelessness and chaotic life circumstances, and even her compliance with oral medications is poor at present. As worryingly expressed recently by one of the Street Health nurses
“She comes regularly to get her blood sugar levels checked, but we know and she knows that this will be high as long as she is not taking her medications or watching what she eats”.
This Street Health nurse has good rapport with Daisy and has stressed to her that if she doesn’t get her diabetes under control it may lead to amputations. Being able to better manage her diabetes was a motivator for Daisy when she previously got off the drugs and was housed. Daisy epitomises the complex life circumstances of many of the clients seen by the Homeless Healthcare, but also encapsulates the strong relationship of trust that the Street Health team has established with her. In her continuing to come and seek out the Street Health nurses to get her diabetes checked, she avoids ‘slipping through the cracks’; her regular contact with Homeless Healthcare complements the support she continues to receive from her 50 Lives case worker around helping her to secure housing and get support for her drug addiction and mental health needs.