Homelessness Week is a national week to raise awareness of people experiencing homelessness, the issues they face, and the action needed to end homelessness not just manage it.
On Wednesday, 3 August 2022 Dr Jim O’Connell President of the Boston Health Care for the Homeless Program (BHCHP) joined our Housing and Health Symposium from Boston via Zoom. In addition to hearing the work of Dr O’Connell the Symposium explored the gaps and opportunities between housing, health and homelessness.
Boston Health Care for the Homeless Program
Over 11,000 people experiencing homelessness are cared for by BHCHP each year. From the beginning goals were to establish a health services care delivery model to provide continuity of care from shelter and street to hospital, provide care through multidisciplinary outreach teams and establish the capacity to meet the needs of homeless individuals for home-type respite care.
These goals were designed by those served. “We have a consumer advisory board, a group of homeless people who meet every few weeks and several of them are elected to our board of directors,” Jim said. “One of the fascinating and wonderful parts of my life is that the people we serve are the people who hire and fire us.”
Continuity of Care
It became apparent continuity of care was the overriding desire. “They were sick of fragmented care. They were sick of going through an emergency room seeing someone, next time they were sick seeing someone else, never having a regular doctor or nurse or team to take care of them. They wanted the same most of us have in our own lives – a healthcare home, somewhere you go and they know you.
“They were sick of fragmented care.”
“They wanted that continuity of care to go from shelter and street to hospital. We were required from the beginning by the people we were serving to be sure we did our clinics where convenient to them out on the street … but also to be firmly grounded in hospitals.”
Respite Care Program
Another issue was a lack of respite care. “They were mad at physicians in hospitals for sending people back to the shelters and streets when they were way to sick after an admission,” Dr O’Connell said.
“Without knowing anything about what we were doing we opened twenty-five beds where we took care of people coming out of the hospital. We had no model to go on.”
Dr O’Connell recalled the wave of aids and the very first homeless person in Boston to be diagnosed with acquired immunodeficiency syndrome (AIDS) who presented at the respite centre in 1985. “We realised people with AIDS were very fragile and needed a substantial amount of care. Within months we had hundreds of AIDS diagnoses … all of them had slow and horrible deaths. It was traumatic.”
Today, Barbara McInnis House – named after a remarkably generous and talented nurse – is BHCHP’s 104-bed medical respite facility located on the campus of Boston Medical Centre.
Jonathan Shapiera is a former Project Manager who ended up becoming homeless after losing his job abruptly in Darwin and not being able to pay the rent. After nearly three years living in a car, he is now living the consequences of living rough.
Jonathan recalled the challenges of living with diabetes while homeless. “I did not know my insulin kit I had to inject myself during the summer months was absolutely useless,” he said. “Once you’ve got heat on the insulin the whole chemical synopsis of what it is breaks down so badly that you are injecting nothing but water into your veins.
“I got off the streets in 2014. In 2015 they found that I had oesophageal cancer. It is not something you deal with, you either drop dead or you need to do something. I have no oesophagus anymore, I spent 14 hours on the table.
“My spinal cord was crushed.”
“In 2016 they found I had a spinal cord deficiency. My spinal cord was crushed. Sleeping rough in a car was the likely cause. I had a major crush in one area and a secondary crush in another.” Jonathan spent four hours on the table and 23 surgical staples.
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Between ongoing diabetic issues and spinal surgery, he needs assistance from a carer and his health circumstances continue to plague him during his post-homeless phase. Recently he suffered a heart attack requiring open heart surgery due to a continual drop in sugar levels.
Jonathan points to the post-homeless period of support as being inadequate. “The contracts you have where post-homeless support is concerned is twelve months, that’s it, no more money, you are on your way you are on your own,” he says. Six months later the body breaks down, seven months later you are in hospital. That’s still happening in Perth.”
Issues were fleshed out through an expert panel discussion between Chief Executive Officer of Ruah Community Services, Debra Zanella; Institute for Health Research, University of Notre Dame Australia Professor Lisa Wood; Chief Allied Health Office, Senior Policy Officer, Suzi Taylor; Homeless Healthcare Medical Director Dr Andrew Davies and Lived Experience Advocate Jonathan Shapiera.
“Fundamentally, housing is a health solution,” Professor Lisa Wood remarked in the opening panel reflection.
“You cannot separate the two. All our data no matter which way we chop it up and look at it, the longer people are on the street, the more their health deteriorates, and Jonathan has shared that this morning. The body keeps the score in terms of trauma and the legacy it leaves in terms of health, and it is the same with homelessness. We have to get people housed with the right kind of housing with access to social support and health services with continuity of care.”
Perth’s Respite Centre
Dr Andrew Davies reflected on meeting Dr Jim O’Connell in Boston in 2011.
“Ever since I saw their respite centre, I thought it would be a fantastic idea to have one in Perth,” Dr Davies said. “There were a few things about their respite centre I thought could be done better. One of which was their respite centre looks like a hospital – and I hate hospitals.”
Dr Davies explained how thanks to funding from East Metropolitan Health Service, they were able to open a 20-bed facility. It is a place “where people can go when they are too sick for the streets but not sick enough for hospital”.
Off the back of a discussion about the problematic nature of pilot health programs not being extended sustainable funding by governments despite strong evidence the program is successful, Debra Zanella observed the need for “political will”.
“We have a lot of evidence, and I don’t think the question is more evidence although it is always important to evaluate but I think it is political will,” she said. There is no mechanism currently where we pilot things and have good evidence, a seamless system for that coming into a commissioning process and a commissioning process that doesn’t then divide the sector or distort the evidence. The evidence out of the very early 50 Lives 50 Home project was compelling. When you spoke to politicians or policy makers they were convinced. But the mechanisms that allow us to interpret that back into a commissioning process that causes collaboration is absent.
“I think it’s a political issue and a political narrative that we are still to nail and that we don’t have all the levers for. We need to get more sophisticated and more collaborative in the way we commission, we don’t do it very well.”
In speaking about the activities of the Chief Allied Health Office (CAHO), Suzi Taylor spoke about the work being undertaken to improve the integration between homeless and health.
“One example I want to provide is aligned to the No Wrong Door principal,” she said. “CAHO is looking at strengthening the workforce in mainstream hospital systems with a better use of the no fixed address so when that’s flagged in the system what do we do with that information. Does WA Health know where to refer people when they come into the system.
“We are supporting a pilot – the Discharge Facilitation Fund – which Professor Wood is evaluating for us. It aims to reduce discharge back to the streets and homelessness and there are seven hospitals involved across WA. They are provided with brokerage funds.
“We have had the homeless health portfolio in CAHO since 2020 and we are developing an action plan on lots of options from when we commissioned Professor Wood and a cross-agency advisory committee to look at the potential options for the WA Health system and what we need to act on immediately. There are five streams we will be working on across the next three years and the first one is service delivery.”
Homelessness Week 2022 would not be possible without the support of our sponsors: Lotterywest, the WA Alliance to End Homelessness, Department of Communities, Fleetwood Australia, Uniting Church in the City and Beyond Bank.
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