Emergency departments at public hospitals, already often stretched to the limit, are increasingly meeting homeless people presenting for help.
It’s a delicate situation. Medical staff are dedicated to helping those in need, but an emergency medical department is simply not the best place to help — so what is the solution?
Amanda Stafford, clinical lead, Royal Perth Hospital Homeless Team, says generally, six or seven people of no fixed address present to the RPH emergency department each day, with most presenting with medical, substance abuse or psychiatric issues.
Dr Stafford says the ED is not the ideal place to solve someone’s underlying issue of homelessness. “Rough sleepers have appalling health with an average life expectancy of around 45 years, and understandably often present to hospital EDs to deal with their health issues,” she says.
“The problem is not with them coming to the ED, but that unless the underlying social issues (ie homelessness) are fixed, their health will not improve in any durable or meaningful way.
“Homeless people are some of the most vulnerable and marginalised within our community, and often experience high rates of chronic health conditions, complicated co-morbidities and reduced life expectancy,” she adds. “There is no question of trying to stop the homeless population from coming to EDs — they’re not a nuisance. We need to be able to help deal with the underlying problem of homelessness. Overall, this is a community problem but given homeless patients present to hospital often, it’s a good place to find them and start the process of linking them with appropriate support networks to improve their health and wellbeing.”
Responding to improve outcomes
Dr Stafford says the RPH Homeless Team is bringing the specialist homeless medicine GP practice, Homeless Healthcare, into the emergency department and wards of RPH to see all the homeless patients they can find and provide the medical input needed for their ongoing care. “We also have a Ruah Community Services senior caseworker in the team who works with the patient to find options for accommodation and support services,” she says. “The program has seen some really positive outcomes in helping to connect homeless people with support services in the community, and was also recently announced as a finalist in the WA Health Excellence Awards.”
Anne O’Sullivan, clinical lead for the Emergency Psychiatry Team at Sir Charles Gairdner Hospital and Fellow of the Royal Australian and New Zealand College of Psychiatrists, says at SCGH there is a dedicated EMT that works alongside the ED staff, which is a necessity given the large volume of patients who present to the ED with acute mental health issues.
“We also work closely with our social work team in the ED to provide care for patients who may be homeless, and they will try to refer the patient to agencies that may assist with finding accommodation,” she says.
Dr O’Sullivan says not all people who present to EDs with an acute mental health issue require long-term hospitalisation, but they do require ongoing treatment and support. She says at times some may require a crisis admission to their short-stay psychiatric unit, (mental health observation area), which is separate to the ED.
Dr O’Sullivan says currently there are limited services available for people who are homeless, especially in an emergency situation. “It can be very difficult to access emergency crisis accommodation quickly, especially from the ED,” she says. “We’ve often had to admit people that cannot be safely discharged as they have nowhere to go, such as patients with a disability.”
She suggests there is a need to look towards what works in other cities within Australia, as well as around the world to help improve the healthcare and safety of people who are homeless. “For example, additional specialised units such as a mobile clinical outreach team (MCOT) would allow more consistent mental health treatment and linkages into longer term supportive services,” she says.
‘Initiatives such as Street Doctor and MCOT are fantastic as they provide ongoing health care and case management for many people through Perth and the Fremantle area. Continuing this model and expanding these services would be invaluable. A central CBD bulk-billing health service that is available to homeless people who can access GPs, social work plus mental health services would also be ideal, and offer an alternative to EDs,” she adds.
“A 24/7 drop-in centre for homeless people would offer a place of safety and support as an alternative to EDs.”
“Ongoing follow up care can be challenging for our homeless patients, as it can be very difficult to link them in with a service that will provide consistent medical and psychiatric follow-up, as they can often be itinerant in their quest to find secure accommodation,” says Dr Anne O’Sullivan.
“Often the best services are (those) that offer mobile outreach to homeless people. Services such as the Mobile Clinical Outreach Team (MCOT), which runs out of City Community Mental Health Clinic, and is linked to the RPH Bentley Health Group, is excellent and would benefit from further expansion. MCOT is a proactive mental health outreach service that works with people who are homeless or at risk of homelessness, having a serious and/or persistent mental illness.”
“Some of the key issues we see in terms of dealing with homelessness include a shortage of affordable housing options for anyone on a low income, and a lack of funding to the homelessness non-government organisations that can employ the caseworkers needed to work with homeless individuals and get them into housing and provide appropriate longer term support,” says Dr Amanda Stafford.
“In WA, we have the Alliance to End Homelessness, a collaboration of many agencies, which have come together with the common goal of ending homelessness in WA, especially chronic rough sleeping, the most extreme end of homelessness. Ultimately, it comes down to whether our community is willing to get behind this because that’s what will drive change.”
“Although the emergency department is not always the most appropriate place for people to present who are not critically physically ill, we need to remember that when people have extreme mental distress and are suicidal this is also an emergency, and they need to be seen urgently,” says Dr Anne O’Sullivan.
“People who are homeless are often stigmatised and marginalised from society, and there is often a poor understanding of how they became homeless in the first place. Homelessness can be caused from numerous factors and can happen to anyone. Not all people who are homeless live on the street. They may couch surf or live in overcrowded accommodation that is not suitable.
“We often see young people who have had family conflict at home and been evicted, and now have nowhere to go. We see women and children who are homeless due to domestic violence, and older people who have lost their homes due to financial problems and/or loss of a spouse. We also see people with disabilities that are left homeless due to carer burnout.”