How healthcare help for the homeless helps us all

Perth GP Dr Andrew Davies’ experiment in taking primary care to the homeless began with $10,000 in personal savings and a 2am lightbulb moment that inspired him to start running mobile clinics at drop-in centres out of his car.

Now, the Homeless Healthcare charity is a leading light in providing joined-up services to the city’s most marginalised and vulnerable patients while – almost inadvertently, it turns out – slashing costs to the tertiary health system.

Importantly, the charity is also a leader in adding to international evidence on the huge impact that coordinated primary care and housing services can have on improving outcomes for homeless people and keeping them out of hospital.

“This is one of the things we have really struggled to emphasise to funders; they just don’t believe us when we tell them how much these patients use the tertiary system,” Dr Davies, the Perth charity’s CEO and medical director, told The Medical Republic.

“We looked at 500 top users of ED from our practice – in one year there was $70 million in tertiary hospital costs. And they are only the ones who are attached to us. What are the ones who are not attached to us costing the system?  It is just amazing to me.”

Thanks to a research partnership with the University of Western Australia, Dr Davies can cite some staggering numbers to convince authorities of the wisdom of supporting the charity’s service model.

“We are able to tell them, we’ve got multiple patients and they are costing you hundreds of thousands of dollars a year.”

Dr Davies came late to general practice, after a list of specialties failed to excite his interest during nine years as a hospital doctor. He found his calling after a mentor suggested he join Perth’s Street Doctor service, working from a van at night to treat the homeless.

“It instantly gelled with me, that you had multiple chronic problems in front of you in a social environment that was really challenging. Where the hell do you start? I found it fascinating, working it through, getting people coming back.”

After three years, however, he started to struggle with the perpetual cycle of illness, dysfunction and despair.

“We were going out in the evenings. Everyone was drunk or off their head on drugs, they needed to be sutured up, you arranged for them to come back and talk about their diabetes. But that didn’t happen because they’d come back drunk and need suturing up again.

“I felt like I was watching people die.

“It was really obvious to me that lack of housing had a terrible impact on people’s health, and that if you didn’t work with agencies that got people rehoused, you weren’t really going to be improving their health much.”

Then, in 2011, came the lightbulb moment. He convinced an outreach worker to join forces and used his own $10,000 in savings to buy equipment for a mobile clinic.

The plan was to visit two drop-in centres for homeless people, giving each centre 3.5 hours per week. But within three months, he was providing 40 hours of clinic, there was so much demand.

“The model worked. It was during the day, people were sober. They had gone to the drop-in centre. They had eaten, they had showered, they could actually think about their health, plus the people who were supposed to be helping them get rehoused were in the same building.

“We had two drop-in centres, drug and alcohol rehab; anywhere homeless people were, we were trying to get in.”

Homeless Healthcare soon opened a clinic in north Perth aimed at people who had been rehoused and wanted to avoid the drug and alcohol scene of the drop-in centres. The “transition” clinic now accounts for half of the group’s practitioner consultations.

By design, and partly by accident, the group has continued to grow in unexpected directions.

It has added a nurse outreach service for homeless people living in parks, an in-reach service at Royal Perth Hospital and an after-hours support service. The mobile clinic now commands three vehicles, and the charity employs five doctors, 25 nurses and four administration staff.

The Perth in-reach service, based on London’s Pathways Program, claims two hours of GP time and six hours of nurse time per day, paying visits to patients who are homeless and those previously known to Homeless Healthcare.

“It is surprisingly hard to find homeless people in the hospital because often they give an address,” Dr Davies said, offering a clue as to why the healthcare burden of homeless people has gone under the radar.

However, breaking new ground in partnership with state-run health has required a bit more work, compared with working in a not-for-profit basically as a private GP.

The parks outreach project, launched in 2015 to connect with people sleeping rough in public places and encourage them to think about their health, seemed hopeless initially, Dr Davies said.

“After six months I thought, what have I done? It doesn’t seem to be making any difference. But then people started trickling into the clinic. It took that long to get the engagement.”

The after-hours service, launched in 2016, works in conjunction with the “50 Lives 50 Homes” program, modelled on the Housing First project pioneered in New York around the year 2000 using the approach of giving people secure housing and then putting other supports in place.

It runs two teams, each comprised of a nurse and an outreach worker from one of the social services, who go out in the evenings to help people in the housing program.

Writing in the latest issue of the MJA, Dr Davies describes “William”, a complex patient with a background of trauma, abuse and acquired brain injury, whose life has been transformed since he found safe accommodation with a friend.

William presented to ED eight times during 2016 and 2017, resulting in five inpatient admissions totalling 58 days and associated costs of $145,318.

His medical profile included sepsis, drug and alcohol intoxication, polypharmacy overdose, a rectal pressure ulcer, aspiration pneumonia, cellulitis of the lower leg, a suicide attempt, an arm abscess, hypothermia and injury from assault.

“The guy has been housed for nine months now, and he hasn’t used the health system once, apart from us,” Dr Davies told TMR.

“What goes along with that is that he’s stable on Suboxone, he’s not using, and he’s living somewhere safe, so he’s not getting beaten up. It’s great to see that side of it.”

A new project is to set up a medical recovery centre for people leaving hospital, intended to stop the pattern of early readmissions by patients with insecure housing – a group that includes people who live in boarding houses or are couch surfing, women escaping domestic violence and people with a history of trauma.

It’s another case of joining the dots. In the government’s eyes, homelessness, housing and health fall under separate areas of responsibility.

“I sat in a meeting with the housing minister last week and he said, is this a housing solution or a health solution? I said, it’s both. It didn’t seem to twig that things can happen across government departments. They have to work together.”

People ask why he works with the homeless.

“There are a lot of sad stories, a lot of people pass away. With people who have a life expectancy of 45, you can’t expect your patients are not going to pass away,” Dr Davies said.

“But so many people do so incredibly well.  I have seen people who have been abused as children, on the streets since a teenager, and they are in housing now, looking after their own kids.

“And you just think, wow, I was a little part of that story that managed to get them in, said the right thing at the right time and they thought, I’m going to try – right now.”

The charity is an exception in the Australian context, driven by the determination of one individual, but in Perth, and in the rest of the country, there is a lot more to do.

“What we have in Perth does not exist anywhere else in Australia.  Brisbane probably does the most, but they struggle with GPs. Townsville is just starting up. Sydney and Melbourne are not as coordinated in their care of homeless people.

“I never expected it to turn out as it has. There hasn’t been that central person in other cities to drive it. There have been bits and pieces, like street services put in place by the PHNs. They could do more,” Dr Davies said.

He is encouraged to think that GPs have more knowledge of how to deal with these most disadvantaged patients.

“What has changed is our understanding. These days there is enough research out there to say that most homeless people have been traumatised at some point. So you assume it, rather than wait for them to tell you they have been traumatised.

“It helps explain the behaviours. It makes it easier to ask the right questions, to get to the issues. Trauma is such a difficult thing. I’ve had patients for 10 years, and they will suddenly tell you they were sexually abused or something. You think, it makes so much more sense now.”

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