By Dr Tracey Weiland MAPS, Senior Research Fellow and Dr Gaye Moore, Honorary Research Fellow, Emergency Practice Innovation Centre, St. Vincent's Hospital, Melbourne

Homeless people encounter multiple barriers to accessing services for their general health, housing, employment and psychosocial needs (Anderson, 1992). These barriers include long waiting times, inflexible scheduling, inadequate service options and complicated admission criteria. Critically, health service providers need to understand the difficulties faced by people who are homeless and that standard health services do not meet their needs. Service availability that is limited to the usual business hours or where a set appointment is required may be unsuitable or unfeasible for this population. Homeless people have competing needs related to obtaining food, clothing, shelter and keeping safe. These characteristics and the barriers related to standard models of service delivery mean homeless people frequently attend emergency departments (EDs) for psychosocial health needs when in crisis (Phillips, Brophy, Weiland, Chenhall & Dent, 2006). Thus EDs are used as a default service due to their 24-hour a day accessibility. Over 10 per cent of ED presentations are by homeless people and the ED re-presentation rate is threefold for homeless people compared to those in stable housing (Moore, Gerdtz, Manias, Hepworth & Dent, 2007). Although the traditional role of EDs is the provision of acute healthcare, they are beginning to be recognised for their strategic positioning in the early identification, engagement and referral of those experiencing homelessness.

The Federal Government's Green Paper on Homelessness (Australian Government, 2008) acknowledged the need for reformation of mainstream health services to enable an holistic, preventive approach to managing homelessness. In contrast to most health services, St. Vincent's Hospital Melbourne provides an integrated, multi-system and multidisciplinary model of care for the homeless that embodies the principles that the Green Paper outlined (Phillips et al., 2008). Here we describe this model and available research, advocate for its replication across other health services, and call for greater involvement of skilled psychosocial care providers in EDs across Australia, with expertise in engaging the homeless.

The St. Vincent's model

St. Vincent's Hospital Melbourne is unique in its flexible, mulitdisciplinary service for the homeless. In its most basic form it consists of: (1) an holistically-focused ED; (2) ED-based care coordination; (3) The Cottage, a short-stay inpatient service;
(4) addiction medicine services integrated within the ED and The Cottage; and (5) a homeless outreach program for the mentally ill. One of the important components of the model is the links with the community.

Holistically-focused emergency department

An integral component of the St. Vincent's model is the ED, which provides acute medical care and acts as a central point for case finding. A culture of comprehensive, holistic health care is fundamental; medical and nursing staff are encouraged to address not only the acute medical issues their patients face, but all issues that may be impacting on their health. Consequently, a compassionate approach is expected rather then viewed as an inconvenient ‘non-medical' responsibility (Phillips et al., 2008).

Situated within the ED is a 24-hour ED Mental Health Service which provides acute mental health assessment, and consultation and liaison with staff of the ED and inpatient units. An holistic approach is enabled by close working relationships with ED care coordinators and addiction medicine staff and strong links to the homeless outreach services. With a particular focus on high prevalence conditions, the service at St. Vincent's began as a pilot program. In 2009 the Victorian Government Department of Human Services (DHS) funded Victorian EDs to replicate this model of care.

ED-based care coordination

A multidisciplinary team (ALERT: Assessment, Liaison and Early Referral Team) provides psychosocial input and comprehensive linkage with community-based services to improve the general health and wellbeing of patients with complex psychosocial issues who may be marginalised, or disengaged with other health and psychosocial services. This includes those experiencing homelessness (primary, secondary, tertiary and marginalised), disability, substance use, high prevalence mental health problems and complexities associated with ageing. Situated both within the ED and the community, ALERT is funded by DHS via the Hospital Admission Risk Program.

The multidisciplinary team consists of social workers, occupational therapists, physiotherapists, nurses and psychologists who work in collaboration with the community service sector and internal hospital services. Inherent to the program's framework is a client centred approach and belief in the ability of individuals to self-actualise and learn self-management skills. Assertive outreach and intermittent contact via ED presentations allows continuity of care, rapport and a level of engagement with clients that is critical to the change process. To facilitate engagement and retain a requisite level of flexibility, ALERT has access to flexible funds, various forms of housing and material aid. ALERT care coordinators undertake risk screening, multidisciplinary assessment, referral, care coordination and facilitation of appropriate accommodation. Advocacy, networking and short- to medium-term care coordination are undertaken to improve access to services internally and in the community.

Care coordination by ALERT has been demonstrated to increase clients' level of community engagement and social connectedness, with higher rates of GP access, higher rates of housing and higher rates of service sector engagement (Phillips et al., 2006).

The Cottage

The Sister Francesca Healy Cottage (The Cottage) is a five bedroom terrace house located onsite at St. Vincent's Hospital Melbourne. This one-of-a-kind residential facility provides short-term domiciliary nursing care for the unwell homeless person and is staffed and supported by St. Vincent's Hospital in the Home nurses, personal care attendants, a Cottage Manager and a Cottage Liaison Nurse. The team work collaboratively with physicians and both internal and external services, with the common aim of enhancing the patient's ability to identify and manage his or her own healthcare needs, access preventative health and community support services, maintain or obtain safe and secure accommodation of an adequate standard, and develop or maintain social support networks. Thus the primary function of The Cottage is to improve the health status of the person experiencing homelessness. The Cottage provides comprehensive and continuous care by addressing health and social needs, referral links and care coordinated assistance, and ensures linkage to appropriate health, housing and community care services. An evaluation of The Cottage revealed a decrease in ED re-attendance, hospital readmission and overall length of stay (Compass Consulting Services, 2003). The Cottage has been demonstrated to result in improved health and housing circumstances for those admitted (Neate & Dent, 1999; Compass Consulting Services, 2003).

Addiction medicine services

The Addiction Medicine Service at St. Vincent's provides clinical care to inpatients and outpatients of St. Vincent's. A consultation liaison addiction medicine service integrated within the ED and The Cottage enables collaborative care of those experiencing homelessness and provides direct access to Depaul House, an inpatient drug and alcohol detoxification unit.

Homeless outreach program for the mentally ill

The Clarendon Homeless Outreach Psychiatric Service (CHOPS) provides outreach, support, assessment, case management and linkage for adults with a mental illness who are homeless or at risk of homelessness. It is one of four homeless outreach teams linked to a psychiatric service in Melbourne. Consistent with other St. Vincent's services for the homeless, effective engagement is the cornerstone of the service. The service operates largely 'on clients' home turf' to maximise flexibility, and has formal relationships in place with the ED and The Cottage to effect seamless care. CHOPS also assists in the implementation of Community Treatment Orders, which supports community-based care and sustains an engagement strategy.

Towards a better future

The St. Vincent's model is one of collaboration with both inpatient and outpatient medical services, and external services. It is fair to say that the effectiveness of this model might be compromised if services were offered in isolation or if a collaborative, client-centred focus was not paramount. Operational characteristics that permit flexibility are key to effective engagement of the homeless.

Available data suggest that psychologists are substantially under-represented among ED care coordinators across Victoria (Power & Xavier, 2006). While homelessness itself is not a key focus of most postgraduate psychology curricula, capacities such as rapport building, engagement, respectful communication, and an ability to teach social skills and self-management are key areas in which psychologists have expertise. These same skills are fundamental when providing care to those with complex needs such as the homeless. Consequently, psychologists are appropriately skilled to respond to the growing problem of homelessness.

Shaping the future of healthcare for Australia's homeless population will undoubtedly require significant planning and the adoption by mainstream health services of a comprehensive, integrated approach that is flexible, patient-centred, multidisciplinary, multi-pronged and sustainable. The St. Vincent's model has been operating for over 10 years and provides an excellent example of such a reformed service. This model should be adopted as the norm rather than the exception.

The principal author can be contacted at Tracey.WEILAND@svhm.org.au.

References

Anderson, H. (1992). Healthcare for the Homeless: What role should hospitals play? Hospitals, 66(14), 44.

Australian Government. (2008). Which Way Home? A New Approach to Homelessness. Green Paper on Homelessness, Canberra.

Compass Consulting Services. (2003). Review of the Sister Francesca Healy Cottage (The Cottage). Unpublished report, Melbourne.

Moore, G., Gerdtz, M., Manias, E., Hepworth, G., & Dent, A.W. (2007). Socio-demographic and clinical characteristics of re-presentation to an Australian inner city emergency department: Implications for service delivery. BioMed Central Public Health, 7, 320.

Neate, S.L., & Dent, A.W. (1999). The Cottage Project: Caring for the unwell homeless person. Emergency medicine (Fremantle, WA), 11, 78-83.

Phillips, G.A., Brophy, D.S., Weiland, T.J., Chenhall A., & Dent, A.W. (2006). The effect of multidisciplinary case management on selected outcomes for frequent attenders to an emergency department. Medical Journal of Australia, 184, 602-606.

Phillips, G.A., Moore, C., Cooper, G., Trevascus, B., Izzo, S., Nesbit, S., & Moore, G. (2008). A ‘reformed' mainstream health service - bold ideas in action. Submission to the Australian Government Green Paper on Homelessness, St. Vincent's Hospital.

Power, R., & Xavier, L. (2006). What do ED Care Coordinators Do? Presentation to Better State of Hospitals Conference. Retrieved 25 August 2009 from www.health.vic.gov.au/archive/archive2009/bshconference/ppts/xavier_lorraine.pdf.

InPsych October 2009