Projects

Adapting lifestyle modification interventions and chronic disease management plans for the self-management of chronic disease in homeless and marginalised people (Study done in 2009-2010).

ACKNOWLEGEMENT:
This research project was supported by funding from the Department of Health and Ageing through the ‘Sharing Health Care Initiative’.

CONCLUSIONS

Physical and mental health interventions are crucial to this incredibly under-serviced population.

Client trust and engagement is vital for the success of individual interventions. Once this is established within a centre or community, interactions with a clinical nurse or member of a healthcare team are highly valued and sought after. Consistency of staff, service and programs are therefore essential to maintain this connection.

Novel, innovative group interventions with a casual or humorous theme are more successful in this population than traditional and more serious small group sessions.

Asking members of the homeless community for their participation in the design of resources is extremely valuable.

A number of effective resources have been developed for the management and diagnosis of chronic disease in this population and are currently being used in Mobile GP clinics.

Final analyses and feedback from clients indicate that one-on-one interventions with an experienced clinical or mental health nurse are effective in creating and maintaining positive change in homeless and marginalised communities. The cumulative amount of time spent with a client appears more important than the number of contacts.

Engagement with a clinical or mental health nurse over time may reduce demand on the general practitioner, reduce the number of emergency department visits and increase the number of chronic disease care plans developed. Further work is required to extend and confirm these findings.

This project has formed an effective pilot study to inform future health interventions and the design of engagement and prevention programs within this high risk population group. Conclusions drawn from this study will be used to facilitate future research design and implementation in this field.

 

AIMS

Aim 1: To provide individual/group education to homeless and marginalised people about lifestyle risk factor modification and chronic disease in order to encourage alteration in lifestyle and raise awareness of health and chronic disease in a population that is primarily concerned with day-to-day living, shelter and survival.

Aim 2: Identify those with a chronic disease and develop a self-management plan with the objective of improving the control and self-management of chronic disease in the homeless.

Aim 3: Assess the effectiveness of the intervention in terms of reducing the need for crisis care or altering a person’s lifestyle risk factor profile.

METHOD

A 45-item questionnaire was developed to collect data and act as a measurement tool to assess the benefit of education. It was delivered via interview and was designed to detect changes in measurable outcomes for smoking, nutrition, alcohol and drug use, depression, category of living circumstances/homelessness, BMI, diagnosis of chronic disease and use of emergency services.

Chronic disease management plan templates were developed for the most common diseases or risks found at the initial interviews and individual interventions were designed.

Seventy homeless and marginalised clients were interviewed; 62 became part of the study, of which 33 were randomly selected to be active and 29 received standard care (inactive).

Only 32 clients were followed up after a number of months in the study. The remainder either could not be located, did not wish to remain involved, moved away, or their follow up interview is after this reporting date; and one client died during the study. The dropout rate for active clients (45.5%) was lower than the inactive (55.2%), suggesting that clients who received interventions were more likely to remain engaged and participate in follow up interviews.

A small group program was designed to address lifestyle changes, beginning with communication, goal setting and emotions and then moving on to look at stress management, physical and mental health. These interventions were conducted in the drop-in centres after normal closing time.

Group sessions were modified as a result of feedback and a number of novel and innovative projects were developed.

 

RESULTS

The majority (74%) of clients were male; with 56% categorised as experiencing primary or secondary homelessness. Participants’ ages ranged from 18 to 79 years with 63% between 30 and 50.

Risk factor profile
Smoking: 83% of study participants were smokers; of which 74% smoked >10 cigarettes/rolled tobacco per day. Forty three per cent of smokers said they were unhappy with their levels of smoking.

Nutrition: one-quarter of subjects ate 1 meal or less per day but over 90% drank tea and coffee daily. Fifty per cent had >5 cups of tea and coffee every day and 40% had >10 tsp of sugar daily via their hot drinks. Therefore, for many clients, the processed sugar in the tea and coffee provided at drop-in centres formed a large part of their calorie consumption. Fifty four per cent ate ≤2 pieces of fruit and ≤5 vegetables per week; 41% had fewer than 4 meat meals per week. These figures are much lower than the recommended minimum daily serves of 5 vegetables, 2 fruit and 1 meat serve per day. Fifty per cent had a BMI >25 suggesting increased health risks. Eighty per cent were interested in eating more healthily and 50% were unhappy or unsure about their nutrition.

Physical activity: 73% of participants walked for >30 minutes per day and 57% walked in excess of 60 minutes each day. The majority of clients (73%) did no additional exercise; clearly most reached or exceeded the recommended 30 minutes of moderate physical activity per day. Fifty three per cent of participants were interested in doing more exercise and 56% were happy with their level of exercise.

Daily alcohol consumption: the recommended daily alcohol consumption has recently been reduced to 2 standard drinks per day for both men and women. Thirty per cent of our clients drank more than 2 standard drinks per day and, of those who drank, 51% consumed more than 10 standard drinks each day. Six participants had extremely high consumption of between 22 and 55 drinks each day. Thirty seven per cent of drinkers were interested in reducing their alcohol intake and 30% were unhappy with their alcohol consumption.

Drug use: Fifty one per cent of clients had used drugs recently and, of those taking drugs, the majority (92%) used marijuana, followed by 33% opiate use and 17% amphetamines. Forty seven per cent of drug users were interested in reducing or stopping their drug use although 69% reported that they were happy with their level of drug consumption.

Chronic disease profile
The depression rate amongst our participants was 64% and was clearly the most prevalent disorder in this population group. This highlights the increased incidence of mental health issues in this community and indicates the importance of addressing mental health as part of homeless and marginalised health care. Interestingly, although most clients with depression were receiving pharmacological treatments, 34% still registered as highly symptomatic, with questionnaire PHQ-9 test scores equal to or greater than 15. Undoubtedly, psychological and other therapeutic interventions are required to further improve depression treatment and recovery.

In addition, 29% had diagnosed asthma, 27% had hepatitis C and 9% reported a diagnosis of diabetes. It was interesting to note that disease incidence was higher with client reporting than it was on the clinical database. This may reflect the lack of importance placed on some aspects of health by the client, the limited amount of time available to spend with a client when health services are in so much demand, the nature of consultations which address the particular acute issue occurring at that time or inaccurate recording on the database by the consulting clinician.

Chronic Disease Management Care Plans and Information Resources
The initial client interview, combined with clinical consultations, identified those clients with chronic disease. The main chronic diseases seen in our research population group were depression, hepatitis C, asthma and diabetes and therefore we focused on these areas for the development of self-management plans tailored to the needs of the homeless.

The resources available through beyondblue for depression and mental illness are extensive and these are now easily accessed at each drop-in centre via the provision of the Street Health Racks. A separate simple depression management plan was designed and is attached in the Appendices. This now forms part of the education and plan offered to clients of Mobile GP and includes contact details for health providers and other avenues for help for the client.

Asthma care brochures are also accessible on the Street Health Racks but researchers have noticed that amongst clients, asthma is not thought of as a preventable/manageable disease. In consultation with an experienced asthma educator and clients, the research nurse was able to develop a self-management plan tailored to the population along with a modified Symbicort asthma action plan. Symbicort treatment combines maintenance and reliever therapy into one, a simpler option for homeless clients and more likely to increase compliance with taking medication, rather than having to take separate medications at different times. The plans are available in the Appendices.

In addition, 3 seminars were held by the asthma educator for drop-in centre staff to provide up-to-date information about asthma, current medications and treatments and effective methods of inhaling medication. This ensured staff was knowledgeable on the use of devices such as spacers which are now available at Genesis and Ruah in case of emergency or the need for acute care.

A diabetes type 2 management plan was also developed by the clinical research nurse in consultation with the manager of the Swan Diabetic Clinic and members of the homeless community. The plan includes foot care packs and hypoinsulinaemia packs which are on hand at clinics and provided to clients in need.

The packs comprise the following items:
Foot Care Pack 1x large wipe cut in 2, one half for washing feet, one half for drying feet
1x small soap
1x scourer for callous removal
1x small moisturiser
4x bandaids
1x travel pack tissues
1x pair of socks

Hypo Pack Jelly beans to raise blood glucose levels
3x sugar sachets
1x low sugar muesli bar

Furthermore, in collaboration with Roche, glucometer devices are available for client use at the Genesis and Ruah drop-in centres. With training, clients can measure and record their blood glucose levels regularly. Four devices were also obtained to be given to diabetic clients for daily use; one is currently in use by a research study patient. Monitoring the effectiveness of the use of these devices by Mobile GP is ongoing.

To complement the management plan given to clients, the research staff also created a Clinicians Diabetic Management Care Plan to be used by medical staff in their ongoing management of diabetic cases. This document is attached in the Appendices.

ACTIVITIES

Individual Interventions
Two hundred and seventy one individual interventions were performed by the Mobile GP clinical research nurse with active clients in the study. Contact ranged from 5 to 60 minutes depending on the engagement of the client and nature of the intervention (rapport building, motivational interviewing, cognitive behaviour therapy, support for maintaining changes). These interventions depended on the type of help required or sought by each individual, and included those listed in Table 1.

Table 1. A summary of individual interventions performed by the clinical research nurse for study participants randomised to the active group.

 

Group Interventions
Classic Small Group Program
The sessions were successful for those involved but participant numbers were very low. Consumer feedback indicated that: [1] the requirement that only active clients attend the sessions without their usual companions and friends was a disincentive; [2] clients’ daily schedules spontaneously changed and an appointment to attend a group session appeared to have lower priority over other things such as seeing Centrelink, finding shelter/food; [3] some clients were not able to endure a session without drinking or smoking; [4] group participation had the potential to reveal vulnerabilities to others which could be seen as a weakness and used against them at another time. This reveals the darker side of homelessness where there is a ‘dominate or be dominated’ attitude. Threats, assaults and violence are commonplace and group events may only be successful if they appear non-threatening to clients. Therefore, classic mainstream small group interventions were altered to suit the population and the following more novel and innovative group interventions were designed to better engage homeless and marginalised people.

Street Chef Lunch Project
The Street Chef Lunch Project was started after the clinical research nurse engaged a homeless man with extensive experience as a chef in lunchtime BBQs. These group gatherings and ‘cooking classes’ were designed to use basic ingredients and facilities available to the target population. Participants learnt how to prepare and cook a simple healthy meal on public outdoor BBQs, raising awareness of health and nutrition and providing them with a sustaining lunch. The involvement of the chef also used peer support as a method to increase engagement and positive response to new ideas in similar population groups. Seven lunchtime gatherings occurred during the reporting period and images from these events are in Appendix 6.

Disease risk and blood screening event
A drug use and Hepatitis C talk and free Blood Borne Virus (BBV) screening event was held in 2009 and promoted using flyers distributed at the 3 drop-in centres in the study.

Irrespective of whether people attended the event, the flyers alone served to raise awareness of the importance of Hepatitis C screening in this high risk population as the number of clients requesting BBV testing increased in Mobile GP clinics around the time of the initiative.

Street Pit Stop
Men have been described as the sickest group in society after Aboriginal people and this is even more severe when combined with the effects of homelessness. The majority of the homeless and marginalised who attend the centres are male (72% of study participants were male). Mobile GP does not have the resources to see all the clients that request a consultation and in addition, it is recognised that there is a large proportion of undiagnosed disease in this community. Health often takes a lower priority when many of these people are concerned with basic shelter and survival. With this in mind, the research team decided to modify the existing ‘Pit Stop Program’ towards the needs of this community, to engage them in their own healthcare, raise awareness of the importance of basic health and increase detection of undiagnosed disease. Through consultation with the Department for Corrective Services and modification of the ‘Inside Pit Stop’ used within the prison system a ‘Street Pit Stop’ program was developed including 7 stations as listed below:

  1. Exhaust Check: smoking
  2. Chassis Check: BMI, waist circumference, diabetes risk
  3. Oil Pressure: blood pressure
  4. Tune Up: BBV/STI risk
  5. Fuel Additives: alcohol consumption
  6. Rust Check: drug use
  7. Shock Absorbers: coping skills

 

Promotional flyers, e.g.’Check your bits, pull into the pits’, signage and a Street Pit Stop work order were created and 8 people were recruited from Mobile GP staff, drop-in centre staff, and drug and alcohol volunteer workers. After completion of all stations, participants returned to the registration desk to be assessed and a sticker declaring their outcome stuck to their work order (Hot Machine, Maintenance, Yellow Sticker/Unroadworthy) and they received a Street Pit Stop Pack. Packs contained flyers concerning health, GP clinic times and locations, apple, muesli bar, socks, travel toothbrush and toothpaste, razor, safety pins and a paper aeroplane kit.

During the Street Pit Stop trial at the Ruah centre, 20 people participated, 18 completed all stations, 20% were new clients and all received recommendations to see a doctor. Feedback from participants and from centre staff was positive with comments such as ‘looks like you were really busy’, ‘I think the clients liked it – it’s something different’, ‘that’s really creative’. Note: this intervention was offered to all drop-in centre clients, not just active study participants. All Pit Stop materials are attached in Appendices.

Nutrition education of clients and centre staff
Homelessness often leads to sporadic and unpredictable food intake with great reliance on meals provided by the charities in soup kitchens, residential facilities and drop-in centres regardless of their nutritional value. Donations of food are often, unfortunately, nutritionally inappropriate. Some homeless people receive the majority of their calorific intake from alcohol alone or cups of tea and coffee laden with sugar. In addition to educating clients, offering nutritional education to the providers of food to the homeless was seen as one way to improve the nutritional value of the food available. Researchers met with the staff of the early morning breakfast drop-in centre to encourage the provision of stewed fruit and porridge in the mornings in place of cornflakes + sugar. This initiative was well received and changes to the available food will be implemented. Nutrition expert and charismatic speaker, Helen Frost, has agreed to perform a shortened and modified version of her presentation to coincide with this change.

Street Health Racks
To ensure information is always available even when Mobile GP staff is not present, brochures concerning smoking, alcohol and diet, asthma, diabetes, hepatitis C, depression and anxiety and how to access medical help are available on Street Health Racks at the drop-in centres. In addition, the racks house information on shelter, finance and rehabilitation options. Two new, sturdy racks are housed at Tranby and Ruah drop-in centres. Existing racks at the Genesis drop-in centre have been refilled with new brochures. Resources obtained from beyondblue are extensive and some clients prefer to quietly read information in private rather than speak to a stranger about a sensitive subject. beyondblue bracelets and pens have been popular and serve to draw clients to the subject matter.

Perth Drug and Alcohol Counselling Flyer and Perth Metropolitan Rehab Centre Flyer
These resources were developed for both clients and staff. Often this kind of information is not found all in one place and may not be known unless people have spent a long time on the street or spent years in the drug and alcohol profession. In particular, with this project funding coming to an end, the clients used to regular interventions will need to be referred to other services. They will be made available on the Street Health Racks, at the drop-in centres and in Mobile GP clinics.

Other projects under development

Mental Health Street Photography Project
Creativity and a sense of purpose have been shown to improve symptoms of depression. Certain participants suffering from depression have been given a project to take snapshots of their life and how they see the world as a method of communicating how they feel. Disposable cameras have been provided and films will be developed by Mobile GP with the aim of holding a small exhibition within one or more of the drop-in centres to display the best works. This gives clients a goal to work towards and symptoms of depression are measured before and after the project.

Anti-anxiety MP3 trial
High levels of anxiety are found amongst homeless people. Depression rates amongst participants stands at approximately 65%. Although not measured independently from depression in this study, anxiety and depression symptoms often overlap. Brochures for anxiety and social phobia are replaced more frequently than others in the centres and panic attacks are not uncommon. A method of talking someone through a panic attack has been used elsewhere successfully and this led to the idea of recording a number of ‘tracks’ with both male and female voices for use by clients. The tracks are on inexpensive MP3 devices and can be used to provide anti-anxiety education when required.

Flu Vaccination Clinic
The homeless are more susceptible to infection from influenza than the general population. They have additional stressors and exposure, limited means for care and often have medical conditions predisposing them to severe influenza. Clinics were conducted specifically for vaccinations.

Effect of Interventions
Use of crisis care — of the 70 clients initially surveyed, 19 individuals had used the emergency department in the last 3 months for a total of 36 visits (data taken from self-reporting). Some of the highest users of ED in our population group could not be reached for follow up and so the number of visits for analysis (n) was low. Comparing the active vs. inactive groups though, there is some evidence of reduced crisis care for those in the active group with interventional treatment (Table 2). An increased sample size and longer study duration would be required to confirm this observation and gain statistical significance.

Table 2. Number of emergency department visits in the 3 months prior to surveying in active and inactive clients (self-reporting).

Indeed, although numbers are low in terms of establishing significance, there is evidence to suggest that clients in the active group may be more likely to develop a chronic disease care plan with their clinician (Table 3). This supports our original hypothesis that interventions involving support and education increase self-management of chronic disease and patient health. It should be noted that this approach was always designed to be a long-term initiative.

Table 3. Number and percentage of chronic disease care plans developed with a Mobile GP clinician in active and inactive clients.

Active clients tended to fall into two groups, those with high engagement (defined as 6 or more sessions with the research nurse) and those with low engagement (defined as 5 or less sessions with the research nurse). Those active participants with low engagement had higher consultation levels with the Mobile GP male mental health nurse indicating that clients may prefer one style or gender of health professional over another. Alternatively, this may be due to location and availability of the nurse at the places where the client spends the most time or the initial contact with the patient to establish an engagement. Interestingly, regardless of the nurse involved, patient consultations with a consulting clinician were reduced (Table 4). This indicates that availability of health nurses/therapists may reduce the demand on general practitioners in this population group. This is potentially a very important observation considering the national shortage of doctors, especially in this high-risk community. It is consistent with research showing that interaction with a carer or therapist has a positive effect on health outcomes regardless of the particular method used.

Table 4. Total number of contacts or consultations with the Mobile GP female clinical research nurse, male mental health nurse and a clinician. High and low engagement of active clients was defined as 6 or more sessions and 5 or less sessions with the research nurse, respectively. Average number of doctor consultations per person this would equate to is shown in brackets.

In a small sample size such as this and a complex population with multiple contributory factors to their degree of wellness, the level of ‘background noise’ is high and it can be difficult to accurately tease out the effect of having interventions vs. not having any interventions. There are large fluctuations in homeless stress levels, health and depression scores depending on availability of money, interactions with family/partners, disputes, alcohol or drug withdrawal, having items stolen etc. When analysing results it was most effective to examine the effect on clients who had the most of each intervention type.

When looking at the improvement of risk factor profiles, the two clients with the highest number and duration (8.5–10.5 hrs) of smoking interventions self-reported definite improvement, reducing their smoking by approximately half. Similarly, the three clients with the longest duration of nutrition interventions (2.3–3.3hrs) all had a reduced and healthier BMI. The two clients with the most contact time for drug interventions (2–3hrs) reduced their use of marijuana significantly and one with high opiate use has started on a methadone program and commented ‘I forgot what it feels like not to be in pain’.

Finally, the four clients with the longest contact time for chronic disease interventions (3.3–8.5hrs) all reduced their PHQ-9 depression scores. Perhaps not surprisingly, the individual time spent with the client seems to be more important than the number of contacts in terms of the health benefit gained.

DISCUSSION

The initial Questionnaire proved to be a valuable instrument for both data collection and relationship building with the participants. The content of the interview raised a participant’s awareness of their health and indicated that the researcher or nurse cares about their welfare so can act as a rapport-building and engagement tool on its own. Follow-up interviews were a useful way to make contact with those clients who were difficult to engage. A non-judgemental, calm and friendly attitude is essential in this process. Both the participant and research team benefit from this interaction. Mobile GP services benefit indirectly through raised awareness and positive perception of their physical and mental health services. As a result of seeing the benefits of the questionnaire, a comprehensive biopsychosocial health assessment was developed for the homeless. The assessment is available in the Appendices.

The most effective group interventions were the novel creative strategies such as the Street Chef Lunchtime BBQs with peer support and the Street Pit Stop. Both interventions were fun but also offered people something perceived as valuable, i.e. a good healthy lunch or a quick health check up with a useful showbag at the end.

Flyers and promotional materials using colour and visual humour to grab people’s attention and engage the population worked well, as did offering small incentives required for day-to-day life.

A number of problems were experienced during the project. The number of clients that developed a care plan with the consulting clinician was low. The reasons for this are several-fold. Firstly, there were difficulties tracking down some clients and this reflects the constant turnover of people within this population. Some people see Mobile GP once or twice and then appear to move on; addresses and mobile phone numbers can change regularly so contact is lost. Secondly, addressing self-management of a chronic disease requires attention and energy that for many is required elsewhere. Health often takes a lower priority over shelter, food, clothing and sometimes addiction. Thirdly, the process of engagement and the need to consider the longer term rather than the immediate does not occur easily. Most clients only had a few months of interventions and the effect of these is unlikely to be seen in the 6–8 months of the project but some benefits might be expected after 18–24 months.

The randomisation of clients to active and inactive groups for the purposes of the study created some difficulties in the clinics. Some ‘active’ clients were disinterested in engagement and not ready for change and some ‘inactive’ clients who were well engaged and ready to move through positive change could not be offered additional help. In addition, some group events were offered only to active clients and the fact that they could not invite members of their social group reduced numbers. Word of mouth from peers was a valuable method of engaging this group in events and interventions. Offering certain interventions to only some of the clients also had the potential to create conflicts between clients.

Some unavoidable change in programs and staff turnover led to client disappointment. A certain resignation exists when they have confided in someone and started a therapeutic journey, and the person ends up leaving/abandoning them. Thought processes such as ‘nothing will ever change’ follow and they may be less inclined to engage with similar services in future.

 

Other benefits
Chronic disease self-management resources developed are now given to clients by Mobile GP clinicians to assist with the management of asthma, diabetes or depression maintenance and improvement. Homeless and marginalised clients have certainly appreciated being involved in this resource development and this activity can also serve as an engagement tool. Further Pit Stop activities are being planned.

The regular presence of the research team within the drop-in centres was beneficial, especially the identified presence of a nurse. Nurses are perceived as caring and health educated but less of an authoritative figure, and therefore it is less stressful and more informal than consulting a doctor. Individuals will almost ‘test the waters’ and decide whether they can trust or rely on a service via this contact. The Mobile GP clinical research nurse had many enquiries from drop-in centre clients about general health information, the existence and location of health services, acting as an advocate re missed specialist appointments when clients felt they wouldn’t be listened to, rebooking health appointments, reading or understanding letters from hospitals if they weren’t able to read (sometimes carrying these letters around for months before they found someone to ask), finding out whether a health problem was worth seeing the doctor about, what the doctor was like (‘will she understand me?’, ‘will she tell me off’, ‘I don’t understand big words – she’ll think I’m dumb’) and resolving past issues with mainstream health services facilitating reconnection with a medical team.

There is a sense of hesitancy about closeness and friendship amongst the homeless. Exposing vulnerabilities feels unsafe and confiding in someone can lead to trouble, fights and being taken advantage of/victimised. Primarily to be friendless is to be safe and yet isolation hinders recovery. The presence of a nurse often represents someone ‘safe’ to talk to.

Some comments and feedback from clients are listed below and serve to illustrate how well this one-on-one interaction with an experienced nurse works:

‘I thought if you can have faith I can do it, the least I can do is I can have faith I can do it!’ – client talking about reducing and giving up smoking

‘I thought I ate healthy!’ – client astonished when discussing his diet of meat (mainly sausages) only

‘This is the first time in my life I’ve ever done this’ – client talking about cutting up a carrot and capsicum for a lunchtime BBQ

‘If I can get it together to stop drinking, I might meet a better class of woman’ – admitted by client as main benefit from stopping drinking

‘I think I know why I’m a mess, has to do with something that happened to me when I was a kid. I might tell you about it one day’ – indications of childhood abuse was an often repeated theme of many clients

‘I always feel calmer after talking to you….if I didn’t have you to talk to, I’d smash someone!’ – client suffering extreme stress going through his girlfriend’s court case

‘I can’t believe after all these years, this is the first time anyone has told me this!’ – client with high anxiety talking about the grounding techniques taught to her to relieve anxiety and panic attacks

‘Thank you for not judging me. I thought ‘here we go again’ when we started, but you seem to understand, it’s not that easy’ – client and drug user

‘I sometimes wonder if I’d have ended up differently if I’d had a bit more support when I was a kid’ – client with an abusive alcoholic father and mother working to support 4 children

‘If a lady like you can be bothered with me, I thought I can’t be all bad’

 

RESOURCES DEVELOPED FROM THE PROJECT

  1. 45-item assessment/measuring tool in the form of a questionnaire

This is effective in building rapport and good communication with researchers and also in raising client’s awareness of their own health issues. It is also a good general data collection tool for use in a hard-to-reach homeless population group. Valuable data can be obtained from survey, eg. % smokers, % that consume less than RDI of fruit and veges, % with large daily calorie intake from sugar, % who consume >4 std drinks/day, % with BMI >25, % walking >30min/day, % primary/secondary/tertiary homelessness, % using marijuana, % depression and other chronic diseases etc.

  1. Flyers and promotional materials for Hepatitis C Info and screening event, Street Pit Stop etc

Colourful, eyecatching, attention grabbing, positive feedback received from clients and drop-in centre staff.

  1. Depression Management Plan

This is a simple document outlining the basic things to focus on in physical/mental and spiritual self-care. It is designed in peaceful colours, contains useful local Perth contact information, filling a different niche to many nationally-produced brochures.

  1. Asthma Management Plan, Modified Symbicort Asthma Action Plan and Diabetes type 2 Management Plan for clients

To remind clients about their medication regimen, the nature of the illness, their own responsibility in their health maintenance, how to stay well and other contact numbers.

  1. Diabetes Management Plan for Clinicians

This is a structured and useful reminder for clinicians on comprehensive care for diabetic clients. Although designed specifically for this homeless population, in most cases this tool can be used in all population groups.

  1. Comprehensive Biopsychosocial Health Assessment for Homeless and Marginalised people

A structured assessment tool based on the biopsychosocial model, which includes:
1. Demographic data
2. Social data — living conditions, social supports
3. Developmental history
4. Physical assessment including history
5. Family history
6. Psychiatric history
7. Mental Status Examination (MSE)
8. Drug and Alcohol assessment

Once complete, the assessment will help establish either a tentative or definitive diagnosis, identify risks and needs and indicate beneficial linkages Mobile GP (or indeed other GP clinics) can facilitate with other agencies. With this information, the clinician can inform the patient of treatment options and a treatment plan can be developed in collaboration with the client.

The assessment is designed to be conducted by a nurse and then reviewed by the general practitioner with the patient. Mobile GP aims to conduct the assessment on new and existing clients that are identified as having complex needs and/or chaotic presentations. It is anticipated the nurse will take about 60 minutes to complete the assessment. The nurse will discuss a brief summary including the patient’s self-identified priorities with the GP who then reviews the assessment and develops a treatment plan with the patient. This will facilitate a coordinated, integrated multidisciplinary approach to homeless health. This health assessment is also anticipated to increase identification of previously undiagnosed issues and chronic diseases in this complex and hard to reach population group. An additional benefit is that the majority of the assessment is undertaken by a qualified nurse, reducing the time spent with GP. It is particularly beneficial given the national shortage and demand for general practitioners; none more so than in this demanding field of care.

  1. Perth Drug and Alcohol Counselling Flyer

Developed for both marginalised clients and staff, this double-sided flyer lists alternative drug and alcohol counselling services available in the areas our clients frequent. Although developed at the end of the project, this is anticipated to be a valuable resource as this information is not often found together.

  1. Perth Metropolitan Rehab Centre Flyer

Developed for both marginalised clients and staff, this double-sided flyer lists the rehabilitation centres north of the river in Perth that are likely to be used by clients in need of detox treatment. Although developed at the end of the project, this is anticipated to be a valuable resource as this information is not often found all in one place.