When Health is the Last Priority

Issue 10 Volume 2
Review
Peer Reviewed article

 

Abstract

On any given night, 1 in 200 Australians are homeless. Evidence shows that being homeless is associated
with an increased risk of poor health, yet for many people without adequate housing, healthcare is but a luxury. What can we as advocates for health do when for some, health is the last priority? In an attempt to address this question, this article first provides an overview of the homelessness issue in Australia and explores some of the current strategies for addressing homelessness. An evaluation of the effectiveness of these strategies reveals that while current response-based housing efforts yield positive results, an all-encompassing approach, consisting of response-based and prevention strategies, is needed for more meaningful and effective services in the prevention and management of homelessness. The knowledge gained from evaluating current strategies is useful in direct- ing future homeless policy, specifically, an increased focus on preventative strategies that identify risk factors, prevent homelessness at its source and support families and individuals to maintain tenancy. The final section of this article provides evidence-based recommendations for medical practitioners and other health care workers in the identification, prevention and management of homelessness. These recommendations include recognising patients at risk of homelessness and taking preventative action to ensure they remain safely housed, obtaining a comprehensive social history, understanding the specific needs of homeless people and the barriers they face to healthcare, making timely and appropriate referrals, and practising compassionate care.

Introduction

“Everyone has the right to a standard of living adequate for the health and well-being of themselves and their family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond their control.” Universal Declaration of Human Rights [1]

It is a rainy day in Melbourne city and I am on a street corner, pressing a few coins into the hand of a middle-aged man named George . I wonder aloud what kind of healthcare he has access to, if he ever needs to see a doctor. “Miss,” he replies, “I’m not really worried about healthcare right now. I just need to start eating properly. I’m wasting away.” I look at the greying clothes hanging off his body and I know he is right.

On a separate afternoon in the city, I’m sitting near a busy intersection with a young woman who introduces herself as Myra. She has three copies of The Big Issue held up with one arm and a sleeping corgi with a pink collar – Bailey- cradled in the other.

The magazines sell for $6 each, $3 of which is kept by the vendor. “Kept by Bailey,” she corrects me. “She was kicked in the ribs a few days ago and
is running out of painkillers. Once she gets those, I might look into accommodation for the night. Then I’ll think about food.” She lists her priorities in order of importance. “Dog, accommodation, me.” Healthcare is not even on the radar.

In the medical profession we are often concerned with the latest advancements, the newest drugs on the market or the efficacy of one procedure over another – and we should be. But when confronted with people at the very edges of society like George and Myra, all of that seems superfluous. What can we as advocates for health do when for some, health is the last priority?

In an attempt to address this question, this article will provide an overview of the homelessness issue in Australia and explore some of the current strategies for addressing homelessness and evaluate their effectiveness. This will lead to further discussion on future directions in homelessness policy. Finally, the article will discuss the role of the health system and medical practitioner and provide some recommendations for medical practitioners to adopt in their practice in order to help prevent and manage homelessness for patients.

The homelessness issue

Homelessness is defined by the Australian Bureau of Statistics[2] as a current living arrangement that:

  • is in a dwelling that is inadequate; or
  • has no tenure, or if their initial tenure is short and not extendable; or
  • does not allow them to have control of, and access to space for social relations.

By this definition, homelessness cannot be considered as merely the absence of a ‘roof’. It encompasses persons living in improvised, temporary, severely crowded or otherwise inadequate dwellings, and therefore not all who
are homeless can be seen out in public spaces. In the 2011 Census [3] just over 105,000 people in Australia were estimated to be homeless. This equates to approximately 1 in 200 Australians. Contrary to the belief that homelessness primarily affects older men, 60% of the homeless were aged under 35 years and nearly half were women.

Homelessness is a manifestation of a myriad of social issues, including domestic violence, a shortage of affordable housing, unemployment, mental illness, family breakdown and drug and alcohol abuse.[4] The most common reason for people to seek support from homelessness agencies is financial difficulty, followed by domestic and family violence.[5]

Homelessness is associated with poor health for a number of reasons. Health issues can be both a cause and a consequence of homelessness,
and homelessness may exacerbate illnesses that are pre-existing. Being homeless is associated with increased risk of depression and suicide,[6] poor dental health, eye problems, podiatry issues, infectious diseases, sexually transmitted disease, pneumonia, lack of preventive and routine health care and inappropriate use of medication.[4] When health is the last priority, or when services are not readily accessible, many who are homeless have no choice but to allow illnesses and injuries to progress until they are severe. Consequently, people who are homeless use hospital emergency services at higher rates than the general population, and to be treated for conditions and injuries that are worsened by being homeless.[7]

From an economic perspective, the Commonwealth Government spends annually $30,000 more on people experiencing homelessness for the same services than those who are stably housed. The potential savings, if homelessness and therefore its associated costs were addressed, total up to $1 million per person over an average lifetime.[8]

Decreasing rates of homelessness will allow those who are disadvantaged by their circumstances to rebuild their lives, improve their health, increase their participation in the community and contribute to the Australian economy.[4] In addition, addressing homelessness is a step towards ensuring all people enjoy the fundamental human right of having a place to call home.

Current strategies

In 2008, the first White Paper on homelessness (National Affordable Housing Agreement)[4] was released. The agreement set the ambitious target of halving homelessness by 2020, with plans to increase current investment in homeless services by 55% implement additional housing for homeless people and supporting victims of domestic violence to stay in their homes safely. The paper reported that current efforts to reduce homelessness in Australia were inadequate, and if no additional action was taken, it predicted that rates of homelessness would rise.[9]

As an extension of efforts in 2008, three National Partnership Agreements were made between all Australian States and Territories in 2009 in response to the National Affordable Housing Agreement.

  1. The National Partnership Agreement on Homelessness[10] committed $1.1 billion of funding over 5 years for the construction of 600 new homes for homeless families and individuals as well as provision of homeless support services.
  2. The National Partnership Agreement on Social Housing[11] committed $400 million of funding over 5 years for the construction of new, affordable, social housing dwellings targeted towards people who were homeless or at risk of homelessness.
  3. The National Partnership Agreement on Remote Indigenous Housing[12] committed $5.5 billion of funding over 10 years for the reduction of overcrowding, homelessness and poor housing conditions in remote Indigenous communities.

It is evident from the distribution of funding above that significantly more funding is directed towards building homes and managing homelessness
than on preventing homelessness in those who are at risk. Undoubtedly, both response and prevention-based strategies play crucial roles in the reduction of homelessness in Australia. However, it is important to examine the benefits delivered by each type of service in order to evaluate their cost- effectiveness and direct future funding.

Response-based strategies consistently yield significant positive outcomes for clients. In an evaluation of 14 homelessness programs in Western Australia aimed at moving clients into long- term accommodation most programs exceeded their target number of clients assisted and were able to obtain and maintain accommodation for these clients.[13] Being accommodated
led to improved health, return to work or study, maintenance of sobriety for sufferers of addiction, and restoration of dignity, self-respect, confidence and independence. Similarly, the Accommodation Options for Families (AOF) initiative in Victoria was able to achieve long-term housing for 74 previously homeless families.[14] Clients reported less stress and anxiety, improvements in their children’s health and improved ability to meet their children’s needs in terms of meals, access to healthcare and educational support.

However, the positive immediate and long-term benefits of response-based housing initiatives demonstrated by programs like the AOF are not extrapolated to all programs in Australia. Evaluation of Sydney’s Way2Home service 2012[15] part of Street to Home initiative, which involved assertive street outreach, immediate access to secure housing and ongoing ‘wrap around’ support, revealed that 90% of clients sustained housing over a 12 month period. Clients reported reduced psychological distress and improvements in nearly all measures of quality of life and satisfaction. However, there were no improvements in the low rates of employment, education, training and job-seeking behaviours among clients after the
12 month period of accommodation compared to baseline.[15] A similar limitation is seen with the Housing First approach, which is based on the concept that a homeless individual or household’s first and primary need is to obtain stable, permanent housing, after which more enduring issues can be appropriately addressed.[16] While the retention rate of this approach has been quoted in one randomised control study as 66%,[17] there is no strong evidence to suggest that the Housing First model affects rates of substance abuse, social isolation or loneliness.[18]

The literature makes it clear that simply providing a homeless person with a house is not always enough to facilitate their integration into society, as the underlying social determinants of homelessness such as employment and education are not addressed. In many cases, accommodated clients who receive no additional support will therefore continue to be at risk of social disadvantage or return to homelessness.

Another limitation is that as long as the causes of homelessness are not addressed through prevention strategies, people will continue to become homeless and place overwhelming burden on housing and support services. In
the Queensland Government’s Responding to Homelessness strategy in 2005,[19] $235.5 million of funding was spent on building new homes and providing support services over a period of four years. Initiatives were able to increase the quantity of accommodation and support services, but the gains were overtaken by increasing demand.[19]

The evidence presented here shows that current response-based housing efforts are effective, however only to an extent. Homelessness programs should focus on holistic and sustainable approaches in conjunction with response-based efforts. An all-encompassing approach, consisting of response-based and prevention strategies, is needed for more meaningful and effective services for the prevention of homelessness and the management of those who are already homeless.

Future directions at the policy level

In keeping with the international trend and evidence in reducing homelessness, Australia is shifting away from crisis-based responses that manage the effects of homelessness to focus on preventative strategies that maintain people who are at risk of homelessness in sustainable housing.[20]

The benefits of preventative strategies are long-term and cost-effective. In a report on the Supported Accommodation Assistance Program,[21] almost all clients at imminent risk of homelessness who received support to retain their current tenure remained housed after 12 months. Furthermore, a cost-effectiveness analysis on this program found that the cost of health and justice services is higher for clients of homelessness programs than in the general population, however, the potential cost offsets by providing assistance to these clients is substantially greater than the cost of support.[21]

Women and children escaping domestic and family violence are particularly vulnerable to homelessness, with the majority of women seeking assistance from homelessness support services in Australia for this reason.[5] They are therefore a major target for preventative strategies and initiatives. An evaluation of the ‘Staying Home Leaving Violence’ (SHLV) initiative,[22] which involved intensive case management, an integrated system with partnership with key agencies and elements of community awareness, showed success in supporting women to maintain tenancy in situations of domestic violence. The authors concluded that Australia should implement provision of homelessness prevention schemes that are as extensive as the current provision of refuge and crisis accommodation. Furthermore, an unrestricted eligibility criteria, good social marketing and the provision of both practical and emotional support were identified as key elements of an effective preventative strategy in this cohort.

Based on this evidence on current and previous strategies for reducing homelessness, both responsive and preventative services are required. In saying this, there is an overall scarcity of evidence regarding the structure and effectiveness of preventative strategies, as few preventative strategies have been implemented in the past. Consequently, there is currently no clear model to aid in the design and execution of new preventative programs.[23] However, what evidence there is shows that preventative strategies hold promise for long-lasting, cost-effective reform, and as more programs of this kind are implemented, their effectiveness can be evaluated and the information used to shape future policy and practice. Housing services alone are not sufficient in addressing the issue of homelessness, and should always work in the context of a supportive framework that aims to maintain people in their homes.[23]

Current best practice for the identification, prevention and management of homelessness for medical practitioners and health care workers

Health practitioners can play a significant role in reducing homelessness through early interventions, preventative strategies and responsive strategies. Their role can be divided into three key areas of action:

  1. identification of those at risk of becoming homeless, particularly where a health issue may result in homelessness;
  2. initiation of preventative care in those at risk of becoming homeless, including referrals to non-clinical support services;
  3. and provision of targeted healthcare towards those already experiencing homelessness.

The first step in the prevention of homelessness in the healthcare setting is to recognise those who are at risk of becoming homeless.[24] Key risk factors include mental illness and substance abuse; marital breakdown and a history of abusive relationships, transitions out of institutionalised care and financial difficulty.[25] In young people, the three groups most at risk of homelessness are Indigenous school students, young people from single parent and blended families, and teenagers who have been in state care and protection.[26] The Indigenous population is continually over-represented in the homeless population, especially in remote areas, where 71% of clients at specialist homelessness services were of Aboriginal and Torres Strait Islander descent.[3]

Furthermore, gaining a good social history can facilitate in the identification of at-risk patients. Patients may not always present to their general practitioner with these social issues as their chief concern, therefore routine questions around mental health, substance use, occupation status, family relationships, financial stressors and current living situation should be used in every consultation, regardless of the presenting complaint.

In some situations however, obtaining a helpful social history and assessing risk based on this history may prove challenging for medical practitioners. For this reason, tools such as the Homelessness Assets and Risk Screening Tool (HART) from Canada have been developed.[27] The HART consists of a patient questionnaire and includes questions on current housing status, income and education and social supports. The HART was evaluated in a clinical context and showed promise in identifying risk and protective factors in individuals in the community.[27] The HART and similar tools could therefore be used to identify at-risk individuals in the setting of general practice or community service.

Enquiries about social history and housing status should extend beyond general practice. The National Affordable Housing Agreement[4] has put forward a ‘no entry into homelessness’ policy as part of its strategy for reducing homelessness. The policy has a focus on the hospital setting as an opportunity for enquiring into a patient’s housing situation and ensuring that they are discharged with housing arrangements in place. A study conducted in the United States [28] showed that assessing the housing status of a patient at discharge was independently associated with higher rates of discussions about cost of medications, physical activity levels, diet, transportation, and mental health follow-up.

In those identified to be at high risk of homelessness, it is then important to address the health and social issues specific to that person in order to prevent their relationships, jobs and housing situations from being compromised. A large proportion of this action involves referral, for example to mental health services, addiction clinics, social workers and financial counsellors.[29] The Homelessness Australia webpage also contains a useful list of specialist services for referral of at-risk patients.[30]

In addition to recognising and managing those at high risk of homelessness, clinicians should also be able to provide services to those who are already homeless. The medical care of a homeless person requires an understanding of both their specific needs and the barriers they face to healthcare. A recent report on a healthcare provision program for the homeless in the Netherlands[29] identified a need for the care of homeless patients to be holistic and multi-faceted. A narrow focus on the patient’s acute physical problems resulted in patients who are homeless feeling neither heard nor understood, which negatively affected the frequency of their service use. Treating only the presenting complaint is of little value as homelessness can impede on adherence to treatments and lead to reoccurrence of and worsening of health problems.[31]

In response to the need for holistic care, practitioners in the afore mentioned Dutch program also increased cooperation with institutions such as addiction centres, mental health care institutions, case management organisation, domiciles, employee recruitment centres and welfare institutions as the program progressed. This allowed practitioners to address social problems, that were often strongly linked to the patient’s current health issue, through quick and efficient referrals. In addition, liaising with homeless shelters also improved treatment adherence as shelter staff were able to supervise medications and encourage clients to attend follow-up appointments.[29]

In addition to understanding the healthcare needs of a person experiencing homelessness, practitioners should also be aware of the barriers they face in accessing healthcare. Over half of people who are homeless have mental health and substance abuse issues requiring counselling or treatment, but they are less likely to access health services due to inability to afford co-payment, inadequate insurance coverage, prioritising health below housing and food and lack of information on what help is available.[32] While the three former barriers call for changes to public policy, the latter barrier is an issue that health workers can directly help to address. Acquiring and passing on knowledge of the services available is a simple yet effective way to provide practical help to those who require it.

Many of the issues faced by homeless people, including domestic violence, mental illness and substance abuse, are deeply personal and sensitive in nature. When doctors practise empathy, such as mirroring the patients’ nonverbal cues, patients feel more comfortable and give fuller histories. [33] Furthermore, compassionate management of homeless adults in hospital has been shown to decrease repeated visits to the emergency department.[34] Indeed, the importance of empathy and a humane focus on individuals who are homeless may be underestimated. Most importantly, empathy is a component of a clinical encounter that anyone can offer, including students who might lack the knowledge and expertise to provide clinical advice. One does not have to be a policy-maker or a healthcare worker to make a positive impact on a homeless person’s life. Towards the end of our conversation, I asked Myra if there was anything one could give to someone like her that was better than money. Her answer came without hesitation, “say a kind word. Don’t look down on them. When people walk past, read my sign, and ignore me – that hurts. But a kind word really helps.”

Conclusion

A paradigm shift in the approach to reducing homelessness is occurring in Australia, with an increased focus on preventative strategies that identify risk factors, prevent homelessness at its source and support families and individuals to maintain tenancy. Increasing the funding allocated for prevention-based programs will allow reach to larger populations sustainably and exert a greater effect. However, as long as there are still people affected by homelessness, provision of affordable housing and homeless support services will continue to be an essential part in the larger homelessness reduction strategy.

In the health care setting, identifying and addressing underlying social issues, such as domestic violence or mental illness, should be a fundamental part of every clinical encounter. Healthcare practitioners are suitably positioned to recognise the risk factors for homelessness and taking appropriate preventative action to ensure that their patients stay safely housed. Furthermore, when health is the last priority, the provision of targeted, accessible, holistic and compassionate healthcare is more important than ever. It is by this combination of prevention, targeted support and collaboration between governments and service providers that the health of homeless persons may be improved and the overall prevalence of homelessness reduced.

Cecilia Xu

Cecilia is a third year medical student at Monash University in Melbourne. Homelessness is an
issue that she has felt strongly about for a long time, but felt lacked the knowledge and con-
fidence to act on her concerns. It is her hope that this article will offer practical suggestions
for improving healthcare for the homeless population and empower current and future health professionals like herself to be a part of the solution to homelessness.

Acknowledgements
Conflict of interest declaration

Conflicts of interest

No conflicts of interest declared

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