Improving health access for homeless people in Cork

As we arrived in Cork to meet Nurse Elaine Conlon from the Ault Homeless Integrated Service (AHIS), we were greeted by the Cork News front page report “Homeless numbers rise fast in Cork”. The cold weather, Christmas season and death of homeless man Jonathan Corrie outside the Dáil had focused media attention on those sleeping out, not only in Dublin but also around the country. The Cork News reported an over 500% increase in rough sleepers. This meant approximately 25 people sleeping out in the city every night.

 

Walking around Cork city with Elaine, the smaller size of the city and homeless population compared to Dublin as well as the closer proximity of the services was noticeable. As we walked Elaine meets one of her patient defaulters and reminds him to turn up for his appointment. We met two mental health nurses (John Mc Carthy & Atracta Burns) doing outreach to patients. We drop into the large Simon Community hostel that provides emergency and supported temporary accommodation as well as a comprehensive range of services, and to the large Vincent De Paul hostel for men which is overlooked by the Elysian apartment complex – a major local symbol of the Celtic Tiger. During the morning spent with Elaine I realised that it was not just the size of the homeless population that made a difference to care for the homeless in Cork; importantly, the structure of the carefully designed Adult Homeless Integrated Service (AHIS) impacted how care was delivered.

 

Background
The AHIS service was established in 2000 following a radical move by the Government to bring local health authorities, health boards and voluntary agencies together to address the issue of homelessness1. The director of Social Inclusion recognised the benefit of integrating services, and realised that a doctor alone would not be able to answer all health needs of this population and so put together a multidisciplinary team. The major change in the service delivery model was that the AHIS would target the homeless where they were staying rather than waiting for them to present, often far too late, to OPDs, doctors surgeries and hospitals.

 

Service purpose and ideology: 
The service aims to provide access to health care to homeless adults and remove barriers to that access. These may be people without medical cards or access to social welfare payments. A barrier to getting medical card is not having an address for example living in squats.

 

The service works with strong links to mainstream Primary Care services. “We have a very strong set of GPs around the city who are generally very amenable to having homeless people register with them” Elaine explains.

 

The service provides care for those not currently linked in with mainstream services but consistent attempts are made to integrate people into the mainstream services. The aim is that each homeless person has their own GP.

 

The service: 
From its establishment the health team was made up of a GP, general nurse, two communities mental health nurses, a psychiatrist and psychologist, addiction councillor and an administrator. Two CWOs specifically for homeless clients are situated at Homeless Person’s Unit. All homeless people are required to link into the HPU prior to accessing services.

Clinics are held in Simon Hostel Day Centre and St Vincent’s Hostel. Deerpark House (emergency accommodation for men) is attended by General and Mental Health Nurses. GPs, nurses, psychiatrist and mental health nurses see pre-booked patients as well as those presenting on the day. An outreach service is provided according to a care plan. The service uses the Safetynet web based IT system which means that all team members can access records regardless of site.

The service operates through a generic medical card number. Prescriptions are faxed to a community pharmacy who delivers medication to the hostel collecting original script on delivery.

 

Services provided:
The majority of the homeless people presenting to the system have mental health problems. The strong emphasis on mental health among the team appears to match the needs among this population. Dr Maura Duggan (AHIS Psychiatrist) says that homeless people present with the full range of mental health problems and that most of the team’s work is with people with severe and enduring problems.

 

Dr Duggan describes the causes of her clients’ difficulties as rooted in structural and personal issues. She describes structural factors as loss of home, of social networks and or family or ineligibility to required services for example by migrants who are HRC affected. Inbuilt stressors such as uncertainty and stigma are also a huge stress. Personal factors which can be the significant in the evolution of homelessness include mental illness, substance misuse, addiction, and adversity in childhood. These factors commonly coexist which contribute to reduced ability to cope with the stresses inherent in living in homeless services. Poor mental health itself can also increase the likelihood of homelessness and the stressors of being without home can increase anxiety and depression, Dr Duggan explains.

 

While Dr Duggan believes their service is good at what it does “we can’t be all things to everyone”, she acknowledges. While the AHIS ensures that homeless people can be seen more quickly and more intensively it is still a basic service without the full complement of disciplines. The team is unable to offer some of the specialist interventions available in mainstream services (e.g. dialectical behavioural group therapy, old age services home-based crisis services). There may also be unmet need for counselling and other supports for people whom psychiatric services would not be appropriate, she explains. For Dr Duggan the novel aspect of AHIS is that it is established within a Primary Care structure with mental health, GP Addiction and nursing services within a single team.

 

As well as providing clinic services in the hostels and outreach to those currently homeless, the team also visits those who have been housed or living in supported housing. Problems do not all abate once people are housed so the AHIS health team support the voluntary agencies outreach teams.

 

General medical care involves dressing of wounds treatment of minor injuries and abscesses, referral to other services, linking in with mainstream GPs and importantly giving people the confidence to attend appointments. The team works closely with the HSE addiction service in Cork and residential services throughout Ireland. The GPs or nurse also screen for blood borne viruses referring on to appropriate services.

 

Elaine says that her aim is empower people to self-care and to give them the confidence to attend appointments and access the care and treatment their entitled to.

 

Referral pathways AHIS

Referrals can originate from key workers, local health services or the homeless person themselves. Referral to the mental health professionals in the team is by GP/or Psychiatric Sector (local generic or hospital teams) transfer to the psychiatrist. The psychiatrist assesses the patient and then refers to others members of the team.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Advocacy for clients is part of the day-to-day work of the team. There are good relationships with local hospitals and Elaine assists in encouraging compliance in improved attendance by homeless patients for outpatient appointments this means that the person does not have to miss an appointment and go back to the end of a waiting list. She can also speak to the relevant service if an appointment is missed to explain and get a new appointment or if necessary assist by taking bloods and sending the results.

 

Changes over time
While the bulk of the problems homeless people present with still tends to be mental health and addiction issues, Elaine can see a change in the people and problems presenting. “There are younger people now presenting and more women” she says. This means that the services have to adapt and provide for women’s health issues such as contraception and pregnancies. Pregnant women have to be linked into social services.

 

At the other end of the spectrum are those with symptoms of old age. Life on the streets can age people before their years giving rise to people with symptoms of old age whether elderly or not. “People may not want to go into conventional nursing homes yet but are not suitable for hostels as they need access to home helps and care staff or on site nursing”. Elaine sees the need for a respite or intermediate care centre to discharge homeless people to from hospital or to be used where nursing care may be required but hospitalisation is not.

 

Elaine says that there are some areas where health care for homeless people could be improved. A gap recently filled since our interview was the lack of a dedicated social worker. Improved access to chiropody and occupational therapy is also needed according to Elaine. Methadone prescribing in the hostels is also something she would like to see reinstated. Other plans are to improve screening and make Implanon available to homeless women.

 

Impact of the service
The service clearly brings care and services to homeless people many of whom would otherwise not access them. The continued support by the service through outreach has undoubtedly contributed to the successful housing of over 70 people by St Vincent De Paul over the last two years. Overall, Elaine measures impact more modestly saying “building confidence and enabling people to care for themselves is a key indicator of success”. The service aims to build trust and provide a professional, non-judgemental service while all the time keeping the door open.

 

 

1    A day in the life of Cork city Integrated Homeless Service, June 2003, The Pulse