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  • Homelessness a new idea- used to be wanderers/associated with monasteries, searching for work
  • Homelessness associated with "non-human" status from settled people, post-war idea (displacement at that time)
  • Modern times, 3 categories:
    • gypsies and circus performers
    • wanderers with a fixed base (migratory farm workers)
    • refugee, for whom homelessness is an accident and not a way of life
  • homeless individuals
    • peddlers, tinkers, swagman, migratory labourers, vagrants, beggars and sailors
  • 21st century

Definition of homelessness

  • Primary - without conventional accommodation (e.g. sleeping rough or in improvised dwellings)
  • Secondary - frequently move from one temporary shelter to another (e.g. emergency accommodation, youth refuges, "couch surfing")
  • Tertiary - accommodation that falls below minimum community standards (e.g. boarding housing and caravan parks)

Local context

  • 105237 homeless in Australia
  • City of Sydney has a biannual street count. 25 Feb 2013: 269 rough sleepers
  • 37 homeless patients admitted in SVH at the tie of the street count 30 of these were rough sleepers (Caritas)

Pathways into homelessness

  • housing crisis
  • family breakdown
  • substance use (more long term; harder to exit from homelessness)
  • mental health
  • youth homelessness --> adult homelessness (more long term; harder to exit from homelessness)

More support/resources needed for long-term homeless to get out of it.

St Vincent's Homeless Health Service

  • Assessment Team
  • Outreach Team
  • Way2Home Health Team
  • Emergency Department Social Worker
  • Tierney House
    • Work with most vulnerable rough sleepers. Link them in with mainstream healthcare, hard to engage with them, take healthcare to them on the street (drug+alcohol, mental health, related physical health)
    • Halfway between community and hospital bed (expensive)
    • It is a house where these people live, social workers help people with cooking etc
    • Get them used to being a person again

Facilitate access to mainstream healthcare

Service use

  • 2007/8 a total of 5011 homeless people presented to the SVH ED, averaging 7 presentations/day
  • Homeless Health Service (HHS) - over 750 service requests annually
  • There are on average 401 clients accessing the HHS

Outreach team

  • Last 6 months from Sep 2012-Feb 13
  • Assessment team received 317 calls (189 initial)
  • Individual health assessments - 652
  • Outreach (individual clients) - 1053
  • Occasions of service - 1741, 6 months (ring people, call police, take them to GP, X-ray, bloods)

The ED Social Worker assists on average 50 frequent homeless presenters per quarter in the ED

Homeless problems

  • Chronic physical health conditions
  • Acute illness
  • Mental illness
  • Substance use
  • Cognitive impairment
  • Disability
  • History of trauma
  • Social isolation
  • Family breakdown
  • History of custodial sentences
  • History of living in care/institutions
  • Hopelessness
  • Lack of trust in systems (healthcare, housing, financial)

... in addition to homelessness

Features of homeless health care

  1. Partnership
  2. Least restrictive care
  3. Long term engagement
  4. Client goal focus
  5. Flexible care (include rules, regulations with providing service and dealing with their not wanting to participate in society)

Physical health

Feet and teeth! Poor health can contribute to being homeless and being homeless can lead to poor health

  • Respiratory issues - chest infections, pneumonia
  • Skin infections - eczema, cellulitis
  • Poor dental care - gingivitis, dental cares
  • Malnutrition - muscle wasting
  • Musculoskeletal - fractures, deep vein thrombosis
  • Neurological - cognitive impairment: substance misuse, trauma, non compliance with medication
  • Urinary issues - UTIs
  • Infective - hepatitis, STDs
  • Diabetes - type 1, type 2
  • Gastroinstestinal - gastritis, cirrhosis
  • Pain management - complex

Rough sleeper data

  • 156 rough sleepers
  • Clients of Way2Home from july 2010 to May 2012

Rough sleeper age range

  • Mainly 31-60


  • Women have most mental health problems and men have more substance misuse
  • But they're actually similar
  • Basically they both have mental health and substance abuse

Barriers to Treatment

  • Losing medicare card/ID documents (necessary for referral)
  • Keeping appointments with no diary/mobile-phone
  • Rigidity of system
  • intimidating
  • stigma
  • jargon
  • complex healthcare systems
  • adherence to medication
  • no storage (eg. storing meds)
  • Money (for prescriptions)
  • Differing priorities

Prevalence of mental health

Substance misuse prevalence

Outreach case study