Evidence for an integrated healthcare and psychosocial multidisciplinary model to address rough sleeping

Evaluation of a Virtual Health Hub for People Experiencing Homelessness in Sydney, Australia: Ensuring Physical and Psychological Primary Health Care in Crisis Accommodation

INTRODUCTION

Individuals experiencing homelessness have higher rates of chronic disease and face challenges accessing primary care. Virtual health care can reduce health inequity but needs user acceptance. A virtual health hub (VHH) for people experiencing homelessness in Sydney provided virtual GP and psychologist care within a crisis accommodation service. This included nursing assistance.

METHOD

The VHH evaluation assessed the feasibility of the service specifically examining accessibility, efficiency, costs, technology, quality, and outcomes through attendance data, patient measures, stakeholder interviews, and case studies.

FINDINGS

Data indicated 40% client utilisation with high attendance for GPs and/or psychologists. All clients reported a high quality of care, appointment benefits, understanding clinicians, and treatment help, and that privacy was maintained. If the VHH was not available, one-third would not have sought treatment. The majority agreed that virtual care was the same or better than in-person care. Only a few experienced technical issues. Service provider interviews indicated the benefits of accessible and affordable care, perceived reduced hospital presentations, staff time saved, and reduced client costs. Limitations were the lack of physical examinations and lack of follow-up due to temporary accommodation. Strong stakeholder partnerships enabled implementation success.

CONCLUSIONS

The VHH service is feasible and replicable with on-site assistance and stakeholder commitment.

Staying safe, feeling welcome, being seen: How spatio-temporal configurations affect relations of care at an inclusive health and wellness centre

BACKGROUND

People experiencing homelessness also experience poorer health and frequently attend acute care settings when primary health care would be better equipped to meet their needs. Existing scholarship identifies a complex mix of individual and structural-level factors affecting primary health care engagement driving this pattern of health services utilisation. We build on this existing knowledge, by bringing the spatio-temporal configurations of primary health care into focus. Specifically, we interrogate how space and time inflect situated practices and relations of care.

METHODS

This study took an ethnographic approach and was conducted 2021-2022 at an inclusive health and wellness centre ("the Centre") in Southeast Queensland, Australia. The data consists of 46 interviews with 48 people with lived experience of homelessness, including participants who use the services offered at the Centre (n = 26) and participants who do not (n = 19). We also interviewed 20 clinical and non-clinical service providers affiliated with the Centre and observed how service delivery took place. Interviews and observations were complemented by visual data, including participant-produced photography. All data were analysed employing a narrative framework.

RESULTS

We present three interrelated themes demonstrating how space and time affect care, that is 'staying safe', 'feeling welcome' and 'being seen'. 'Staying safe' captures the perceptions and practices around safety, which sit in tension with making service users feel welcome. 'Feeling welcome' attends to the sense of being invited to use services free of judgment. 'Being seen' depicts capacities to see a health care provider as well as being understood in one's lived experience.

CONCLUSION

Spatio-temporal configurations, such as attendance policies, consultation modalities and time allocated to care encounters afford differential opportunities to nurture reciprocal relations. We conclude that flexible service configurations can leverage a relational model of care.

PATIENT OR PUBLIC CONTRIBUTION

Service providers were consulted during the design stage of the project and had opportunities to inform data collection instruments. Two service providers contributed to the manuscript as co-authors. People with lived experience of homelessness who use the services at the inclusive health centre contributed as research participants and provided input into the dissemination of findings. The photography they produced has been featured in an in-person exhibition, to which some have contributed as consultants or curators. It is hoped that their insights into experiences of welcomeness, safety and being seen will inform flexible and relational primary health care design, delivery, and evaluation to better cater for people experiencing housing instability and poverty.

Nurse-led mental and physical healthcare for the homeless community: A qualitative evaluation

Increased morbidity and mortality rates are prominent issues among homeless individuals. To help reduce these health inequalities, dedicated senior mental and physical health nurses have been deployed to work within and alongside local statutory and voluntary organisations. This qualitative evaluation examined the impact of nurse-led homeless healthcare in Warwickshire, United Kingdom. During January and February 2021, online semi-structured interviews were conducted with 17 professionals including the mental and physical homeless health nurses (n = 4), statutory health and local authority professionals (n = 4), and voluntary and community sector professionals (n = 9). Interviews were qualitatively analysed using inductive, reflexive thematic analysis. Data analysis identified three overarching themes related to the meaning, impact and future development of nurse-led homeless healthcare: (1) Nurse-led homeless healthcare and health inequalities, (2) The multi-agency approach of nurse-led homeless healthcare, and (3) Future development of nurse-led homeless healthcare. The findings confirm the benefits of homeless healthcare in reducing health inequalities and promoting a more accessible, flexible and person-centred approach to holistic care. Yet, prevailing organisational and system-level barriers were also identified as currently limiting the capacity, provision and practicalities of delivering nurse-led homeless healthcare. Recommendations were identified with international relevance and included: (i) continued implementation of person-centred healthcare for homeless individuals, (ii) strengthening of organisational collaboration and communication pathways to improve coordinated care, (iii) development of the managerial and structural aspects of provision, (iv) addressing limitations associated with scope and capacity to ensure that delivered healthcare is adequately intensive, (v) increased availability of clinical or therapeutic spaces, and (vi) implementation of long-term plans supported by evaluation and commissioning.

Homelessness, hospital discharge and challenges in the context of limited resources: A qualitative study of stakeholders' views on how to improve practice in a deprived setting

Hospital discharge for people experiencing homelessness is a perennial challenge. The Homeless Reduction Act 2017 (HRA) places new responsibilities on hospitals, but it remains unknown whether this has affected discharge practices. This qualitative study explores stakeholders' views on the challenges around hospital discharge for people experiencing homelessness, in the context of a deprived English city. Semi-structured interviews were conducted with 27 stakeholders. Participants were purposively recruited from local authority, third sector and the National Health Service. Interviews were transcribed and thematic analysis conducted. Analysis generated three main themes. First, a need for better planning and communication with the third sector, particularly around medication, prescriptions and information sharing. Second, the need to improve awareness and 'upskill' hospital staff to work more effectively with people experiencing homelessness, including understanding their needs, the wider support available and HRA requirements. Third, there were calls for (re)investment in a different approach to better support this population, based on outreach and flexibility. The need for improved partnership working and investment was emphasised. Whilst recognising the challenges faced by hospitals, especially within the context of funding cuts, this study highlights the need to recognise the third sector's contribution in supporting people experiencing homelessness in the community. Developing site-specific checklists for practice before discharge (and as early as possible) may help to ensure appropriate measures are in place. Improving legal literacy in the context of what an appropriate discharge is for people experiencing homelessness may help develop staff confidence to challenge the focus on 'quick' discharges.