Why treat people and send them back to the conditions that made them ill? – Michael Marmot, The Health Gap, 2015
"Homelessness is one of the most inconvenient and complex problems facing cities around the world," said my colleague, Dr. Jim O Connell, from the Boston Homeless Healthcare Program (BHCHP). It's rather a bit to hear that Boston is now in its third "ten year plan" to finish homelessness. Despite the success of the Boston & Housing First programs in the houses of many people who have lived on the streets for many years, it has proved difficult to "turn homeless tap".
The reasons include a lack of affordable housing options and a systematic failure to break people's cycle that leaves the correction system without somewhere to live. O Connell has just spent a week in Perth as Raine Medical Foundation Visiting Fellow at PCA. He reports that around half of the people entering Boston homeless shelters indicate that they were "prison" where they were sleeping in the previous night.
These are warning warnings for Australia, where there are joint attempts to complete homelessness against the affordable housing crisis and huge housing housing waiting lists. There are numbers of people being released from Australia prisons to homelessness each year.
Therefore, while ending homelessness in Australia is an essential aspiration, which needs to be supported by a coherent national strategy, multi-understanding action and more money, cities also need better equipment to deal with the effects health and other homelessness consequences until it can be deleted.
Hospital and human costs are high
One of the most expensive consequences of homelessness for any city is the burden on the health system. Although mental health and physical issues can contribute to homelessness, being homeless also increases the risk of many health problems. These include psychiatric illness, the use of chronic and infectious substances and diseases.
Across Australia, people who are homeless are among the most frequent presenters to emergency departments. Their rate of unplanned hospital admissions is high. The average stay is longer.
All of this stresses the resources of our public hospitals, as shown in our recent analysis of data for homeless patients seen at the Royal Perth Hospital.
Globally and within Australia, there is pressure placed on hospitals to reduce the stops in expensive hospital beds. However, after-release care through "home hospital" programs is less expensive is not an option for patients with "no fixed address".
As a result, homeless patients face longer inpatient admissions or discharge when they are too ill about the challenge of living on the street. And that in turn leads to health deterioration and many unplanned readings.
Respite centers offer a solution
Innovative solution to these problems is the medical respite model for homeless people. This started in the United States in the mid 1980's.
A respite center enables homeless people to recover after a hospital in a more home-like environment. Here they can receive follow-up care, social support and connect with community services and accommodation providers.
A more homely non-hospital environment is an essential element, as hospitals can be traumatic for homeless people. Many have suffered violence, sexual abuse, neglect, imprisonment or other forms of trauma, and this is further complicated by the trauma of living on the streets. From Boston experience, therapy, social connection, leisure activities, art therapy and patient support groups are among the healing benefits that can be provided outside the hospital environment.
One of the reasons for bringing Jim O'Neill to Australia this month was drawing on his experience as the founder of the first medical respite center for homeless people in the United States. He started as a 25-bed facility in Boston in 1985 and now has 124 beds. Unfortunately, demand continues to grow – for every bed that is available, there are 20 hospital calls for a bed for homeless patients.
What facilities does Australia have?
The respite center model has thrived in North America, with over 70 in cities across the United States and an increasing number in Canada. Australia has two small examples, in Melbourne and Sydney.
In Melbourne, Cottage is literally a next cottage to St Vincent's Hospital in Melbourne. It has six patients beds, with an average stay of nine days.
Our evaluation of The Cottage, published last week, shows that it provides a valuable alternative and stable period for homeless people. This enables staff to build a trusted relationship and increase patients' ability to control their own health.
Tierney House is a 12-bed short break unit run by St Vincent's Hospital, Sydney. Support and care is provided for around $ 400 a day. This is much cheaper than the average cost of an Australian hospital bed of $ 2,003 a day in 2015-16.
Perth is trying to establish a 20 Australian medical first recovery center for people who are homeless. It is based on the United States respite care model, but with a firm focus on connecting people with long-term housing and other home stay support. Connecting people with a general practitioner through Homeless Health Care will be an essential part of the model, as its GPs and nurses can provide primary care and community continuity to avoid hospital admissions in the future.
As Dr. Andrew Davies, Homelessness Healthcare, and I emphasize recently in the MJA, the absence of safe and safe housing is at the heart of the health differences seen among people who are homeless. This is particularly noticeable when they are discharged from hospital before they are good enough to return to the streets.
Imagine trying to recover from hospital admission without a place to rest and sleep, without slate, no safe storage for medicines, let alone poor access to nutritious food and difficulty in maintaining hygiene wound care.
The need grows
Australia faces rising and unsustainable healthcare costs, aggravated by an aging population and the increased burden of chronic disease. A medical recovery center offers a cost effective solution to the government given the high rates of emergency department presentations and hospital re-admissions when people remain homeless.
Published evaluations of US respite centers show a 24-36% reduction in emergency department presentations. Discounts in inpatient days were 29% and 58%. The reduced use of healthcare equates to millions of dollars in cost savings.
We need to do more than burst the doorbone between the hospital and street street facing people who are homeless across Australian cities. As Andrew Davies realizes: "Tough hospitals treat acute medical problems. If we do not tackle basic chronic diseases and social health determinants of homeless people, we will continue to watch people die gradually on the streets. "
The medical recovery center model provides critical circuit breaking and cost-effective. By enabling "home-based hospital" to people with no home, it reduces hospital admissions.
Rough chronic chorus is one of the most marginalized groups in our society. A medical recovery center offers a safe period of respite where they can be connected to housing and other support to break the homelessness cycle.
AMA adopts a new housing policy for homeless people