ENHANCING PRIMARY HEALTH CARE SERVICES FOR PEOPLE EXPERIENCING PRIMARY IN THE CENTRAL AND EASTERN PRIMARY HEALTH NETWORK REGION

REPORT

February 2018

Sydney Health Community Network Level 1, 158 Liverpool Road Ashfield NSW 2131 Tel: 02 9799 0933 Email: [email protected] www.shcn.org.au

Central and Eastern Sydney Primary Health Network commissioned this project.

Sydney Health Community Network acknowledges the traditional custodians of the land that we work and live on and strongly supports practices that provide culturally appropriate services to Aboriginal and Torres Strait Islander people.

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TABLE OF CONTENTS

TABLE OF CONTENTS ...... 3 ACKNOWLEDGEMENTS ...... 4

ABBREVIATIONS...... 5

EXECUTIVE SUMMARY ...... 6

CHAPTER 1: THE PROJECT ...... 8

COMMISSIONING BODY...... 8

PROJECT OBJECTIVE ...... 8

PROJECT SCOPE ...... 8

PROJECT OUTCOMES AND DELIVERABLES ...... 8

PROJECT METHODOLOGY ...... 11

CHAPTER 2. SERVICE PROVIDER CONTEXT: OVERVIEW OF CESPHN REGION AND KEY SERVICE PROVIDERS 13

CHAPTER 3. POLICY CONTEXT ...... 16

CAUSES OF HOMELESSNESS ...... 16

HOMELESSNESS LEGISLATION AND POLICY – COMMONWEALTH / STATE / LOCAL ...... 16

CHAPTER 4: HEALTH ISSUES FOR PEOPLE EXPERIENCING PRIMARY HOMELESSNESS ...... 17

CHAPTER 5. PRIMARY HEALTH CARE AND HOMELESSNESS – BARRIERS TO ACCESSING SERVICES ...... 20

CHAPTER 6. OPPORTUNITIES TO ENHANCE PRIMARY HEALTH CARE DELIVERY ...... 34

CHAPTER 7. GOOD PRACTICE PRIMARY HEALTH CARE SERVICES FOR PEOPLE EXPERIENCING PRIMARY HOMELESSNESS ...... 35

CHARACTERISTICS OF GOOD PRACTICE SERVICES ...... 35

MODELS OF SERVICE DELIVERY ...... 36

EXAMPLES OF LOCAL GOOD PRACTICE...... 37

CHAPTER 8: DISCUSSION AND CONCLUSION ...... 40

REFERENCES ...... 42

APPENDIX A – EXISTING PRIMARY HEALTH CARE SERVICES IN CESPHN REGION ...... 48

APPENDIX B – POLICIES AND LEGISLATION ...... 51

APPENDIX C – REGIONAL REGISTRY WEEK DATA ...... 52

APPENDIX D - EXAMPLES OF LOCAL GOOD PRACTICE ...... 57

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ACKNOWLEDGEMENTS

Sydney Health Community Network would like to thank all the individuals and organisations that were consulted and provided valuable information for this project.1 This includes people who are experiencing homelessness, rough sleepers, members of the Project Advisory Group, volunteers, employees from community managed organisations and Local Health Districts, General Practitioners, Allied Health practitioners.

SHCN gives thanks to Libby Darlison and The Miller Group for their invaluable work on this project, and to Julie Millard, Consultant in Mental Health for completion of the Report.

1 Unfortunately, SHCN did not receive specific information on the number of people experiencing homelessness or the names of services that were interviewed for this project.

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ABBREVIATIONS

ABS Australian Bureau of Statistics AHURI Australia Housing and Urban Research Institute AIHW Australian Institute of Health and Welfare CALD Culturally and linguistically diverse CESPHN Central and Eastern Sydney Primary Health Network CMO / NGO Community managed / non-government organisation CoS DHIG District Homelessness Implementation Group FACS Department of Family and Community Services GP General Practitioner HAP Homelessness Action Plan HYAP Homeless Youth Assistance Program KRC Kirketon Road Centre LGA Local Government Area LHD Local Health District NAHA National Affordable Housing Agreement NDIS National Disability Insurance Scheme NPAH National Partnership Agreement on Homelessness PHC Primary health care PHCRIS Primary Health Care Research & Information Service PHN Primary Health Network PIR Partners in Recovery program SAAP Supported Accommodation Assistance Program SESLHD South Eastern Sydney Local Health District SGCH St. George Community Housing SHCN Sydney Health Community Network SLHD Sydney Local Health District SVHNS St Vincent’s Health Network Sydney

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EXECUTIVE SUMMARY

This report was commissioned by Sydney Health Community Network and funded by Central and Eastern Sydney Primary Health Network (CESPHN) to examine the primary health care needs of people experiencing homelessness in the CESPHN region. It is extremely difficult to determine the exact number of people who are experiencing homelessness in the region at any one time, with the numbers of people accessing homelessness services increasing at an alarming rate. There are niches of data available however there is no one repository of data collection. Commonwealth and State governments have primarily focused policy responses to homelessness on increasing access to social housing and supported accommodation, and to date, there is no national or state homelessness health policy to guide development of service provision for people experiencing homelessness. The primary health care provider context in the CESPHN region is diverse comprising 18 Public Hospitals, 2 Local Health Districts, 2 Hospital Networks, 5 headspace sites, 1 Aboriginal Medical Service, over 2,400 General Practitioners (GPs), over 4,500 Allied Health Practitioners and more than 480 Practice Nurses. Across the region, there is a range of primary and specialist health care services whose primary target group is people experiencing homelessness or who see a high proportion of people experiencing homelessness through mainstream service provision. People experiencing homelessness are generally socio-economically disadvantaged, have complex comorbidities across a range of physical and mental health conditions and experience significant inequities in relation to access to health services and health outcomes. Compared with the general population, people experiencing primary homelessness have poorer levels of physical and mental health; substantial unmet health needs and significantly lower life expectancy. Common health issues include severe and persistent mental illness, problematic substance use and chronic physical health issues. Many people have reported experiencing significant trauma prior to becoming homeless. There are multiple barriers to accessing primary health care for people experiencing homelessness. These include individual related barriers such as mistrust of health services (often arising from previous negative experiences), lack of awareness of available services, financial and transport difficulties, and difficulty managing structured appointment times. Service provider barriers include lack of flexibility in service delivery (including service location, and appointment times); insufficient focuses on care coordination, assertive follow up and integrated care; lack of provision of trauma informed care; and discriminatory attitudes and practices towards people experiencing homelessness. Throughout the report, a number of needs and opportunities for service improvement have been identified. Different service models across the CESPHN region exemplify characteristics of good practice in primary health care of people experiencing

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homelessness. Four services were showcased in the report including Kirketon Road Centre, St Vincent’s Homeless Health Service, the and Youthblock. The following recommendations have been made:

1. CESPHN supports the development of the inter-sectoral Homelessness Health Strategy, led by SESLHD in partnership with SLHD, SVHN, City of Sydney and Family and Community Services and that this report informs this strategy.

2. CESPHN and service partners advocate for the development of a State and/or Federal Homelessness Health Policy or Framework to guide local priorities and plans.

3. CESPHN considers a range of strategies to strengthen and support primary health care capacity to deliver integrated holistic and trauma informed care, including training and education to primary care providers.

4. CESPHN consider the development of a HealthPathway to support primary care providers around referrals and resources for people experiencing homelessness.

5. CESPHN and service partners advocate for standardised data collection, routine identification of people experiencing or at risk of homelessness in electronic medical records, systems development and training to promote integration of care and regional analysis.

6. CESPHN consider commissioning after hours assertive outreach primary health care services for people experiencing homelessness that complement existing outreach services.

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CHAPTER 1: THE PROJECT

Commissioning Body Sydney Health Community Network is committed to ensuring the voices of disadvantaged and/or vulnerable population groups are identified and heard. The Board of SHCN identified in 2016 an unmet need in the population of people experiencing primary homelessness or at risk of homelessness, and commissioned research to identify the primary health care service needs of people experiencing primary homelessness in the Central and Eastern Sydney Primary Health Network (CESPHN) region. Project Objective To identify the primary health care service needs of people experiencing homelessness or at risk of homelessness in the CESPHN region and recommend strategies to enhance the wellbeing of this group. Project Scope The project intended to provide a snapshot of: • The number of people experiencing primary homelessness or at risk of homelessness in the region • The identification of the primary health care service needs of people experiencing homelessness or at risk of homelessness • The existing services that enhance mental and physical health and build resilience available to people experiencing primary homelessness or at risk of homelessness • Any gaps in service provision in the region in relation to primary health care service needs. • The opportunities and potential strategies to enhance service access for people experiencing primary homelessness or at risk of homelessness in the PHN region. Project Outcomes and Deliverables • Request for Tender process undertaken and a Consultant engaged • Project Advisory Committee established and consulted throughout the Project • Approved project plan • Consultation with a cross section of people experiencing homelessness and with relevant health and homelessness stakeholders • In consultation with CESPHN, establishment of a database of services and support groups for people experiencing homelessness or at risk of homelessness • A report of findings with recommendations relevant for CESPHN and key service partners.

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Members of the Project Advisory Group were:

Alison Sneddon Senior Health Service Planner SESLHD Julie Millard Director SHCN

Kirsten Gridley Social Worker Community Mental Health Camperdown Libby Darlison Consultant/Director The Miller Group Lisa Parcsi Manager Integrated Care SLHD

Lisa Woodland Manager Priority Populations, Primary Integrated and Community Health SESLHD Maha Abdo CEO Muslim Women’s Association

Maria Psaltis Manager Mental Health CESPHN

Matt Flynn CEO Haymarket Foundation

Matthew Larkin Homeless Health Service Manager St Vincent's Hospital

Rebecca Baiada Health Planner CESPHN

Shane Jakupec Regional Manager Neami National

Sharlene McKenzie Aboriginal Community Consultant and Mentor

Sussie Walker Forensic Psychologist

Timothy Graham Social Health & Wellbeing Practice Manager Exodus Foundation

Valentina Angelovska Manager St George Youth Services

SHCN engaged the consultancy services of The Miller Group, who undertook a literature review, consultations with individuals and agencies, provided first drafts of the report and meeting papers, and was a member of the Project Advisory Group. The composition of the Project Advisory Group reflected the diversity of the communities in the region. The group met on four occasions (27/4/17; 1/6/17; 13/7/17 and 21/8/17) and provided, during and between meetings, their knowledge, experience and expertise. The group gave invaluable information and advice to the project, the Consultant, this report and in development of the recommendations. Terms of Reference for the group were developed with a SHCN Board Director the Chair of the meetings. SHCN provided project support. Julie Millard, Consultant completed this report with assistance from members of the Project Advisory Group.

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A database of services and support groups for people experiencing homelessness or at risk of homelessness operating in the CESPHN region was developed and provided to the Planning Unit of the PHN. The draft report and some of its findings have been incorporated into CESPHN activity work plans. A major outcome of the project and this report has seen the realisation of Recommendation 1 with an inter-sectoral Homelessness Health Strategy being in development that is led by SESLHD in partnership with CESPHN, SLHD, SVHN, City of Sydney and Family and Community Services.

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Definition of Homelessness For the purpose of this document the following definition of homelessness2 is used: Primary homelessness: people without conventional accommodation (e.g. living on the streets, in deserted buildings, improvised dwellings, under bridges, in parks) Secondary homelessness: people moving between various forms of temporary shelter including: friends, emergency accommodation, youth refuges, hostels and boarding houses Tertiary homelessness: people living in single rooms in private boarding houses – without their own bathroom, kitchen or security of tenure Marginally housed: people in housing situations close to the minimum standard The focus of this Project is to understand and enhance access to primary health care services by people experiencing primary homelessness. It is acknowledged that primary health care is funded at both a Commonwealth level (e.g. services provided by GPs and private allied health practitioners and funded through Medicare, and services commissioned through the PHN) and a State level (e.g. services provided through Local Health Districts, Specialist Health Networks and community managed organisations). Project Methodology The project undertook the following actions to gain an accurate and comprehensive understanding of the extent and the type of health issues prevalent amongst people who experience primary homelessness and to confirm the efficacy of the data collected through Registry Weeks: • A review of the international and national primary homelessness and health literature • A review of health data collected in the Registry Weeks undertaken in the past 2 years across the CESPHN region • Interviews with primary and allied health specialists, i.e. doctors, nurses, psychologists who work with people experiencing primary homelessness • Consultations with people experiencing primary homelessness, and people who had previous experience of homelessness • Accompanied health teams on assertive outreach and, where appropriate and with their consent spoke with people who were rough sleeping.

One of the project’s goals was to identify the number of people who are homeless or at risk of homelessness in the region. However, given the transient nature of homelessness and the absence of a data collection repository accurate data collection was not

2 Adapted from Chamberlain & MacKenzie, 2006; Chamberlain & MacKenzie, 1992

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possible. This report does include Local Government Area’s Registry Week figures though this is not comprehensive or complete for the whole region. Specific homelessness data is due to be released this year by the Australian Bureau of Statistics and this will give more context to the size of the problem in this region. The data collected locally were consistent with international findings on the health indicators for people experiencing primary homelessness.3 4 The project methodology was triangulated and included both quantitative and qualitative data, in keeping with best practice in social research. Although the Project was time limited, every effort was made to ensure that the data collected balanced reliability with validity and was as extensive as possible. A review of the relevant legislation and government policies and guidelines for general practitioners was undertaken to identify the primary health care service needs of people who are homeless or at risk of homelessness. The literature review included international and national research and publications in addition to data from CESPHN, GPs, Centrelink, Local Health Districts, local government and Homelessness NSW. Electronic searches and consultations with service providers facilitated the development of a database of service providers for CESPHN. The Consultant sought verbal consent from each individual for any discussion about their lived experience of homelessness, with no names or identifying information collected. This is in keeping with NSW privacy and personal information protection legislation5. The consultations with individuals reflected the diversity of people experiencing primary homelessness e.g. male, female, trans and fluid gendered, people who are Aboriginal and/or Torres Strait Islander, elderly and young people, and people from culturally and linguistically diverse backgrounds providing an opportunity to identify any differences in the way individuals and/or groups experience primary homelessness and/or differences in their health needs. Qualitative information was obtained by accompanying assertive outreach teams to primary homelessness hotspots such as , Belmore Park, and Hyde Park. Incorporating observation into the methodology by accompanying the integrated assertive outreach teams provided information into not only the complexities and challenges confronting people who experience primary homelessness, it also highlighted the challenges that health and support workers experience as they provide assistance to people, many of whom have complex trauma and high levels of mental illness and substance use problems.

3 Trabert G. Health status and medical care accessibility of single, homeless persons, Gesundheitswesen.; 59(6): 378-86, June 1997 4 Hwang, Stephen W., Homelessness and health, CMAJ January 23, vol. 164 no. 2, 2001 5 Further information at: www.ipc.nsw.gov.au/privacy-laws

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CHAPTER 2. SERVICE PROVIDER CONTEXT: OVERVIEW OF CESPHN REGION AND KEY SERVICE PROVIDERS

The Central and Eastern Sydney catchment spans 666.9 square kilometers. The region stretches from Strathfield to Sutherland, east to , and includes Lord Howe Island and Norfolk Island. Central and Eastern Sydney PHN (CESPHN) is the second largest of the 31 primary health networks across Australia by population, with almost 1.5 million individuals residing in our region. The boundaries align with those of South Eastern Sydney Local Health District and Sydney Local Health District. The catchment population is characterised by cultural diversity and high population growth with more than one third (35%) of the community born outside Australia. By 2031 the region’s population will reach more than 1.85 million, an increase of 28.1% or more than 400,000 individuals.6

6 About Central and Eastern Sydney PHN available at www.cesphn.org.au/about/about-cesphn

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The health service provider system comprises7: • 18 Public Hospitals • 2 Local Health Districts (Sydney LHD and South Eastern Sydney LHD) • 2 Hospital Networks (St Vincents and Sydney Children’s Hospital Network) • 5 headspace sites • 1 Aboriginal Medical Service • Over 2,400 General Practioners (GPs) • Over 4,500 Allied Health Professionals • Over 480 Practice Nurses

Belmore Park Sydney - photograph Julie Millard 19 July 2017

7 Our PHN, available at www.cesphn.org.au/about/about-cesphn

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Primary Health Care Services for people experiencing homelessness Across the Central and Eastern Sydney region, there is a range of primary and specialist health care services whose primary target group is people experiencing homelessness or who see a high proportion of people experiencing homelessness through mainstream service provision. The Tables A, B and C summarise the current services identified. In addition, there are a number of GP practices and allied health practitioners who have expertise in providing physical and mental health care to people experiencing homelessness. Challenges in the health service provider system include: • High turnover and fragmentation of service providers, associated with short- term/project funding • Lack of coordinated service planning and delivery across funding agencies, health care providers and community managed organisations • Lack of integrated care for people with multiple and/or complex health needs • Uneven geographical spread of services targeting people experiencing homelessness across the region, leading to people not receiving services or travelling/moving centrally to access services in the inner-city.

See Appendix A for Existing Primary Health Care Services in CESPHN Region including: • Targeted Primary Health Care Services • Primary Health Care Clinics in Community Managed Organisations • Other Community Managed Organisations providing health information, support and referrals for people experiencing homelessness • Mainstream Health Services whose target groups include a high percentage of people experiencing homelessness.

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CHAPTER 3. POLICY CONTEXT

Causes of Homelessness There is no single cause of homelessness, however poverty must be considered as the most crucial precipitating factor. Without the financial resources to afford safe and secure housing people are at a much higher risk of homelessness. This is particularly the case in Sydney, including the CESPHN region where high property prices combined with a lack of affordable rental properties is one of the key reasons why the incidence of homelessness continue to increase. In addition to poverty and a shortage of housing, homelessness can also be triggered by, and is a symptom of other social problems such as unemployment, domestic violence, family breakdown, trauma, physical or mental illness, substance use problems and financial stresses. People are at highest risk of homelessness when several issues intersect. Homelessness Legislation and Policy – Commonwealth / State / Local Homelessness is a complex and growing social problem. The focus of both policy and legislation at the State and Commonwealth levels has been on the reduction of homelessness through the provision of housing; social housing, affordable private rental housing, transitional accommodation and other types of accommodation. This has presented a major challenge for governments as property prices continue to rise, especially in metropolitan Sydney, and the supply of available and affordable housing is not able to keep up with demand. For more detailed information on current policies and legislation addressing homelessness see Appendix B.

Homelessness Health Policy There is currently no national or state homelessness health policy or plan that identifies priorities for the provision of health services to people experiencing homelessness.

NEED 1: A national and/or state homelessness health policy

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CHAPTER 4: HEALTH ISSUES FOR PEOPLE EXPERIENCING PRIMARY HOMELESSNESS

Many people experiencing primary homelessness have complex comorbidities across a range of physical and mental health conditions. Compared with the general population, people experiencing primary homelessness have: • poorer levels of physical and mental health • significant unmet health needs, especially women.8 9 • significantly lower life expectancy 10,11,12,13 Common health issues for people experiencing homelessness include: • Severe and persistent mental illness • Problematic substance use • Physical disabilities • Chronic physical health issues, including: o Metabolic syndrome; o Cardio-vascular disease o Respiratory conditions including Asthma and Obstructive Pulmonary disease o Liver disease, including chronic viral hepatitis and advanced liver disease o Oral health conditions and o Cancers

NEED 2: Integrated holistic primary health care services for people experiencing homelessness

8 Hwang S. et al, Journal: Universal Health Insurance and Health Care Access for Homeless Persons, American Journal of Public Health, Volume: 100, Issue 8, pp. 1454-1461 9 Ontario Women’s Health Council, Health Status of Homeless Women, September 2002 10 Nusselder, WJ, et al. Mortality and Life Expectancy in Homeless Men and Women in Rotterdam: 2001– 2010 11 Brodie C, et al., Rough Sleepers, Health and Health Care, NHS, 2013 12 Thomas, B. Homelessness Kills: An analysis of the mortality of homeless people in early 21st century England, 2001-2009, University of Sheffield, 2012 13 Reported in ABC news on line: http://www.abc.net.au/news/2014-09-12/australian-homeless-have- shorter-lives-than-some-africans/5741024

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Findings from the literature were confirmed through consultations with local health service providers and local data collection. Local Government areas have conducted Registry Weeks in which people experiencing homelessness are surveyed (See Appendix C). Key findings of these surveys include high rates of self-reported health conditions including: • Physical health conditions, including dental problems, hepatitis C, and asthma • Comorbid mental health problems and problematic substance use; half of the sample reported experiencing trauma prior to becoming homeless. In addition, survey participants reported high levels of use of Emergency Departments and Ambulance services as well as significant periods of hospitalisation. Health service utilisation by people experiencing homelessness was examined in the SESLHD Homelessness Health Data Project (2013)14 that conducted a one-week census across hospital and community health settings. Key findings were: • Of the sample population, 209 people (1.5%) identified as homeless, including 41 people identified as experiencing primary homelessness and 110 people identified as experiencing secondary homelessness • 62% of people experiencing homelessness were men; • 78% of people experiencing homelessness were aged between 25 and 54 years • 11% of people experiencing homelessness identified as Aboriginal; this group was more likely to be experiencing primary homelessness • 87.5% of people experiencing homelessness who presented to the health service during the census period accessed care provided by the Drug and Alcohol Service, Kirketon Road Centre, Mental Health Service and Emergency Departments. • 39 people experiencing homelessness presented at Emergency Departments (48 presentations in total) during the census period, most of who presented to Prince of Wales and Sydney/Sydney Eye Hospitals. Most presentations (59%) related to mental health, substance use and/or injury. It was noted that people experiencing homelessness were likely to be under- enumerated; some data sets were incomplete; unregistered anonymous clients were not included and admitted patients not discharged during the census period were not captured in the data set. The report highlighted significant problems with routine data collection around people experiencing or at risk of homelessness, which were confirmed through consultations with health service providers.

14 SESLHD Homelessness Health Data Project Report (2013) unpublished, available on request

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These include: • There are a variety of health information systems used within primary care (GP and allied health practices; community health centres) and hospital settings; each with differing data fields relating to homelessness and/or the adequacy of current accommodation; not all data fields relating to homelessness are mandatory fields. • There are inconsistencies in the identification, interpretation and documentation of homelessness by health care providers as well as administrative staff • Administrative data (address/no fixed address) for longer term individuals is not always updated over time • Health information systems do not flag homelessness status of individuals; and thereby do not provide system support to track health status and service use by people experiencing homelessness over time.

NEED 3: Standardised and routine data collection with regional analysis

King Street Newtown - photograph Julie Millard 19 December 2017

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CHAPTER 5. PRIMARY HEALTH CARE AND HOMELESSNESS – BARRIERS TO ACCESSING SERVICES

There is a growing body of evidence that suggests that greater facilitation of access for people experiencing primary homelessness, through service models that demonstrate good practice in their service delivery, also deliver better health outcomes for individuals. It is recognised that there are barriers for people experiencing homelessness to accessing services, and there are service provider barriers.

1. Barriers to Accessing Services by People Experiencing Homelessness Barriers identified by people experiencing primary homelessness both in the literature and in the consultations undertaken for this Project include the following: • Lack of awareness of available services • Prohibitive costs • Lack of transport • Level of documentation required e.g. Medicare card • Limited operating hours • Structured appointment systems • Stigma and embarrassment • Previous negative experiences • Perceived poor quality service • Poor communication with service provider or practitioner • Distrust in practitioner.

From the perspective of the person who is homeless, key barriers to accessing GP services include cultural differences and expectations between the GP and the person; not being treated with sensitivity and respect; the requirement to have a Medicare card and/or cost for services that do not bulk bill. Other barriers are the same as those that prevent or reduce access to any primary health service by people experiencing primary homelessness, for example location, lack of transport. In avoiding primary health services where individuals report not feeling comfortable, and because health care is not necessarily the main issue in the lives of people experiencing primary homelessness,15 health concerns may be neglected until they become extreme or even life threatening. In this situation the person who is homeless is more likely to go to the Emergency Department at the nearest hospital where they are

15 For many people experiencing primary homelessness their main concern is surviving day to day, with finding food, shelter and safety being higher priorities

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also likely to be known by staff rather than a GP. This has ramifications both for hospital resources and for the cost of providing the required health care. During project consultations and informal conversations with people who were rough sleepers they were asked whether or not they used mental health services, which were often more physically and geographically accessible, respondents explained that they used services, for any health issue where they felt safe, understood and respected, where they trusted the provider and where they could see the same person(s) rather than a different person/provider each time.

2. Service Provider Barriers One of the significant barriers to access identified in the literature is the lack of coordination and communication between health and homelessness services. This has been confirmed through consultations undertaken in the LHDs. As an example, in late 2015 SESLHD held a Bridging the Gap workshop that was attended by 91 service providers from across the homelessness and health sectors. The major recommendations from the workshop focussed on the need for better communication and collaboration by all stakeholders at all levels of government and between services. Service provider barriers are typically found at three levels, i.e. the organisational and planning level, the service level and the practitioner or health provider level. Each is described in more detail below: • The structure, funding and coordination of services, i.e. the system and organisational/planning level, include the relationships and coordination, between government jurisdictions, federal and state government agencies that fund, or in other ways impact on services aimed at reducing primary homelessness. • Service providers at a service level include government and community managed service providers such as primary health and homelessness services that contribute to the reduction in homelessness. Barriers to access occur when there is poor communication between services, and/or insufficient resources to provide an effective service, or not enough services to meet the needs of a growing number of people in the region experiencing primary homelessness. • The primary health care provider at a practitioner level includes GPs, nurses, psychologists and allied health professionals. Barriers exist where the provider does not provide a service that meets an individual’s needs. This is not limited to performance but to the communication between the practitioner and the individual, or a lack of understanding about the challenges of people experiencing primary homelessness. Specific issues identified include: • Insufficient continuity of care and support for people when exiting state care, including prison, or on discharge from hospital • Lack of standard protocol for referrals

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• Poor information and communication systems between primary health care services and homelessness services. • Poor communication between homelessness service providers and GPs • Lack of awareness by GPs of the existence of homelessness services • Lack of a primary health care health pathway.

Several different reasons for this situation were provided, including overstretched services with too few health or support workers, insufficient funding, and a lack of clarity regarding responsibilities. All of the good practice primary health services provide for people experiencing primary homelessness reviewed for this Report demonstrated a strong individual focus underpinned by an understanding of some of the challenges experienced through the provision of primary health care for a group of people whose lives can often be chaotic and unpredictable. Services had ensured that all staff had the requisite interpersonal as well as performance skills and training and had developed their service with these key factors in mind.

3. Service Coordination Barriers and Gaps Another of the service gaps identified through consultations with service providers, including both primary health care service providers and community homelessness service providers, was the need for better coordination between primary health services and community homelessness services. At this time there is no clearly identified national or state health homelessness strategy, although development of a Regional Strategy has commenced. This will be of great benefit in addressing some of the barriers and gaps identified in this Report and in improving the health outcomes for people experiencing primary homelessness. Primary health care services are the first point of contact for people seeking assistance with a health issue. Commonly for rough sleepers in this region this first point of contact is with a GP or allied health professional who are part of a team of coordinated assertive outreach or by a doctor or allied health outreach worker. If the health issue cannot be addressed in situ, the person needs to be referred for further treatment to a specialist primary health care clinic. For example, to the Kirketon Road Centre where a Medicare card is not required, or to an outreach GP or nurse in a homelessness organisation, e.g. Matthew Talbot or Wayside Chapel or to a GP practice. Where services are working well together, as they do in assertive outreach teams, the individual will be allocated a support worker from a community-managed organisation. For example, Neami National is funded to provide Way2Home16 assertive outreach

16 Neami’s Way2Home is a partnership between Neami National, the NSW Government, and the City of Sydney. The service has a housing first approach, supporting people who are homeless with complex

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services in the City of Sydney LGA and to work with individuals to improve their mental health and wellbeing. However primary homelessness is growing and as more people are rough sleeping support needs are also increasing. This increases the difficulty of ensuring that the assertive support required is available to ensure individuals receive follow up health treatment, attend medical appointments and adhere to their treatment plan. Health workers in assertive outreach teams work to prevent rough sleepers from becoming ill, for example by providing influenza vaccines, and by early intervention strategies so that health issues are addressed quickly. This works to reduce the exacerbation of health issues and has the potential to reduce the need for hospitalisation while providing an opportunity for health promotion and education. For people experiencing primary homelessness health is not always their first concern. Other issues such as obtaining the next meal or a safe place are often more significant and health issues are not addressed until they become so serious that they require expensive and extended treatment.

4. Lack of Systemic Trauma informed Care and Practice It is widely recognised in the literature on homelessness, confirmed by the consultations undertaken for this Project, that people experiencing primary homelessness have almost universally experienced at least one traumatic experience in their lives.17. Posttraumatic stress disorder (PSTD) is most commonly associated with a history of trauma, however there is growing evidence and growing awareness that other disorders, such as those experienced by people experiencing primary homelessness for example depression, anxiety disorders and substance abuse are the result of a history of trauma. The Hospital Trauma and Homelessness Initiative18 found that while approximately 4% of people in the general Australian community experience a traumatic event more than four times in their lives, for the 115 participants in the study the rate was 97%. This means that almost all health practitioners who provide primary health care for people who experience primary homelessness will be treating people who have experienced significant trauma in their lives. The 97% of people who had experienced four or more traumatic incidents in their life represent the homeless population generally, not specifically the 6% of the homeless population that are rough sleepers - the focus of this project. While a 97% figure is health needs to obtain and sustain accommodation. www.neaminational.org.au/sites/default/files/neami_way2home_assertive_outreach_fact_sheet.pdf 17 Buhrich N., et al, Lifetime Prevalence of Trauma among Homeless People in Sydney, Australian and New Zealand Journal of Psychiatry, Volume: 34 issue: 6, page(s): 963-966, 2000

18 O’Donell M., et al., The Trauma and Homelessness Initiative. Australian Centre for Posttraumatic Mental Health 2014

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revealing, two additional points should be noted. Firstly, that rough sleepers have the highest levels of trauma, and secondly that some sub-groups within this population require particular attention in terms of their history of trauma, i.e. Aboriginal and Torres Strait Islander people and refugees. The Mental Health Commission of NSW19 has noted that the principles and approach embodied in Trauma-Informed Care and Practice are integral to the reform process occurring nationally not just in mental health but also across human service systems and sectors generally. While some homeless services have introduced trauma informed care and recovery oriented practice into their service provision this is not universal. Mental Health Coordinating Council (MHCC)20 has focused resources in the past four years on providing strategic direction, policy, development of tools i.e. Recovery Oriented Service Self-Assessment Toolkit (ROSSAT) and the Trauma Informed Care and Practice Organisational Toolkit (TICPOT), resources, and workforce education and training to enhance recovery oriented and trauma informed care and practice. Trauma-informed care and recovery oriented practice is acknowledged by LHDs as an emerging but fundamentally important treatment model in mental health planning and education documents21, and is also included in the program for the South Eastern Sydney Recovery College. Consultations with allied health workers and GPs further emphasised the importance of trauma informed practice by services that provide primary health care to people experiencing primary homelessness. The need for more education and training in TICP for GPs and allied health workers was clearly identified.

NEED 4: Universal Trauma-informed Care and Practice (TICP) training22

19 Mental Health Commission of NSW, Trauma-informed Care and Practice Forum: Report and Evaluation, 2013 20 MHCC is the peak body for community-managed organisations providing services to people with lived experience of mental health issues in NSW www.mhcc.org.au/sector-development.aspx 21 See for example SESLHD Mental Health Clinical Services Plan 2013-2018 and SLHD’s Mental Health Service Strategic Plan 2015-2019 22 Trauma informed care is a strengths-based service delivery approach “that is grounded in an understanding of and responsiveness to the impact of trauma; that emphasizes physical, psychological, and emotional safety for both providers and survivors; that creates opportunities for survivors to rebuild a sense of control and empowerment." (Hopper, Bassuk, & Olivet, 2010, p.82 cited at www.centerforebp.case.edu/practices/trauma). This definition is generally agreed on by clinicians and other health practitioners

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5. Barriers specific to General Practitioners and Allied Health Professionals While there are recognised barriers for people experiencing primary homelessness when accessing GPs and allied health professionals, there are also challenges for all in working with people who are homeless, especially people who are rough sleepers. As noted elsewhere in this report, mental illness is common amongst the population of people experiencing primary homelessness. When combined with a history of trauma and/or substance use, behaviour may be disruptive, erratic or unpredictable, or manifest in terms of unkempt appearance or poor personal hygiene, and individuals may not keep appointments or regularly take medication. There are relatively few standalone GP practices currently in the CESPHN region providing primary health care services for people experiencing primary homelessness. Increasing the number of treating GPs outside the inner city will be particularly important. While this may have little impact on the ‘city drift’ which is due, amongst other things to the prevalence of services, both primary health and homelessness it will increase access to primary health services in other areas of the region. A further issue for practices in providing an appropriate and effective primary health care service for people experiencing primary homelessness is that a range of more complex issues involving mental health and substance use problems as well as at least one other chronic physical health problem also accompanies many apparently immediate health problems. Because of these multiple needs, a multidisciplinary team approach is often more effective for people experiencing homelessness.23 24 Some GPs and allied health practitioners may feel that they do not have the necessary support, education, time or skills to provide effective treatment and assistance for people experiencing primary homelessness with complex health and other needs. Barriers to access and engagement identified in the literature and from stakeholder consultations with GPs include: • Medical education and training does not include homelessness • Wide ‘social distance’ between the GP and the person who is homeless with both finding it difficult to see things from the other’s perspective • Lack of understanding of the reality of the daily lives of people experiencing primary homelessness • Feeling overwhelmed by the complexity of issues and number of problems • Expectations of success • Perceived role of the GP with respect to homelessness • Feelings engendered in the consultation

23 Lyons, A. RACGP, Homeless Healthcare, Good Practice, Issue 7, July 2017 24 Jego M, et al. Improving access and continuity of care for homeless people: how could general practitioners effectively contribute? 2016

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• Ability to tolerate uncertainty • Perceptions of power sharing in the consultation • Role of the receptionist • Limited resources and access to specific information • Practice workload and time.

6. Barriers in Community Mental Health and Alcohol and Other Drugs Services Services where people indicated that they did not feel as comfortable attending included community mental health services and to a lesser extent alcohol and other drugs services. These services are the responsibility of both LHDs and while people experiencing primary homelessness do use them often, a couple of respondents reported they had used one of these services once but would not go back as they felt they were “discriminated against” and made to feel that they were a problem. Increasing the network of mental health and alcohol and other drugs services across the CESPHN region that can provide the primary health care required by people experiencing primary homelessness may take the pressure off other services, particularly in the inner city, and broadens the good practice service network across the CESPHN Region. There is no specific data collection available for LHDs to accurately determine what percentage of people experiencing primary homelessness access community mental health or alcohol and other drugs services, nor was there any evidence to confirm the veracity of complaints by individuals who are rough sleeping. Currently the data collection system only provides the opportunity to record a No Fixed Abode data collection item when an individual who is homeless presents to a mental health service. Staff in mental health and alcohol and other drugs services have to work with a range of people and it may well be that additional support and/or training is required, including for receptionists and administrative employees to ensure appropriate and effective communicate with individuals.

7. Particular Service Barriers and Challenges for Vulnerable Population Groups While many of the barriers to access of primary health care services for people experiencing primary homelessness are common, some groups within the cohort experience different or greater challenges and barriers. These groups and the particular challenges and barriers they experience are set out below.

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Aboriginal and Torres Strait Islander People Aboriginal and Torres Strait Islander Australians are over-represented in the homeless population. According to data from the Australian Institute of Health and Welfare25, 26 on Census night in 2011 an estimated 26,743 Aboriginal or Torres Strait Islander people were experiencing homelessness27. Taking into account the size of this population group, 1 in 20 Indigenous people were homeless on Census night in 2011, i.e.14 times the rate for non-Indigenous people (1 in 284 people). The Inner Sydney Registry Week in December 2015 found that 17% of the 516 people surveyed were Aboriginal or Torres Strait Islander people.28 In 2011, 51% of Aboriginal and/or Torres Strait Islander homeless people were female, compared with 42% of non-Indigenous homeless people. About 42% of the Indigenous homeless population were aged 18 or under, compared with 23% of non-Indigenous homeless people.29 Many Indigenous people experiencing homelessness are in remote or very remote areas (60%) but many of the other 40% are in urban environments with the latest City of Sydney Street Count reporting 17% of people sleeping rough were Indigenous.30 Aboriginal and Torres Strait Islander people generally, but particularly people who experience homelessness, have low levels of access to primary health care.31 Respondents who are Aboriginal and/or Torres Strait Islander indicated that they preferred to use an Aboriginal primary health care service with a clear majority indicating that they would choose to go to the Aboriginal Medical Service in Redfern even if it meant travelling to get there because they felt much more comfortable and less discriminated against being treated for an injury or an injury by ‘their mob’. However, a significant minority reported they would go straight to a hospital because “they are used to us there” and “I might need a bed”. A woman with a baby reported that she chose to go to her GP whom she had known for a long time.

People from Culturally and Linguistically Diverse Backgrounds There is significant literature that demonstrates that people from culturally and linguistically diverse backgrounds often experienced significant challenges accessing

25 Australian Institute of Health and Welfare, Homelessness among Indigenous Australians, Canberra Cat. no. AIHW 133, 2014 26 Australian Institute of Health and Welfare, A profile of homelessness for Aboriginal and Torres Strait Islander people, Cat. no. IHW 43. Canberra: AIHW, 2011 27 This is not restricted to primary homelessness but also includes people in temporary or insecure accommodation, boarding houses, living with family or friends. 28 See Appendix B 29 AIHW 2011 op. cit. 30 This compares to the representation of 2.5 % of Indigenous representation In the population as a whole 31 Department of Health, Development of a new National Women’s Health Policy, Consultation Discussion Paper, 5.2.3 Barriers to Accessing Health Care, 2009

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primary health care services due to cultural, language or economic reasons. However, there is little research on the barriers to access for people from culturally and linguistically diverse backgrounds who are experiencing primary homelessness. The services interviewed who work with people at different levels of homelessness, i.e. secondary or tertiary homelessness confirmed that the barriers for people from culturally and linguistically diverse backgrounds were significant. In addition to cultural or language barriers other factors identified included the sense of shame felt in some cultures as a result of homelessness and the potentially hidden level of homelessness when people were likely to stay with and be supported by family or relatives. The majority of asylum seekers and humanitarian migrants in Australia live in the community on bridging visas while they wait for their asylum claims to be resolved. More than half of these asylum seekers have no access to a financial safety net.32 Many have no form of family or community support and many move constantly in and out of homelessness. Refugees and asylum seekers are particularly vulnerable to homelessness due to language, literacy and cultural barriers, difficulty accessing services and very often being discouraged by their own communities from relying on ‘welfare’ or ‘handouts’.33 For asylum seekers, the experience of homelessness and long-term destitution not only has a detrimental impact on their health and welfare, but also hinders their capacity to satisfy the requirements of the protection application process34. Interviews with staff at the Asylum Seekers Centre described some of the barriers to accessing primary health care, which included: • Lack of awareness of services • Cultural barriers including but not limited to language barriers • History of trauma • Trust and mistrust of services and often government agencies35 • Discrimination and shame36.

32 Department of Immigration and Citizenship, Annual Report 2008–09 cited in e-GPS, General Practice Solutions, August 2013 33 Liddy N, et. al. Australia’s Hidden Homeless, Hotham Mission Asylum Seeker Project August 2010 34 Ibid. 35 Flatau et al in their research on the Housing and Homelessness Journeys of Refugees in Australia, AHURI Final Report 256, December 2015, note that although refugees generally have fairly low levels of trust for people in the community as a whole they have high levels of trust for doctors and hospitals. 36 Assistance was sought from the staff at the Refugee Council on gaining this information from individuals who were refugees and who had experienced homelessness

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Women Over the past 4 years there has been a significant increase in the number of Australian women especially, but not only older women single women37,38 39 becoming homeless. Women, especially Aboriginal women and women from CALD backgrounds are particularly vulnerable to domestic violence and to financial insecurity, two of the key factors leading to their homelessness. While special homelessness services attempt to meet the accommodation needs of women who become homeless, there are still many women who are rough sleeping. While homelessness as a result of fleeing family and domestic violence is now receiving greater government and community attention (although not necessarily reducing the rates of DV or its impact on homelessness) the increasing numbers of older single women becoming homeless as a result of financial insecurity gains far less attention.40 Reasons other than domestic violence or financial insecurity resulting in homelessness amongst women, particularly older women, include: • Declining rate of home ownership • Age and discrimination in the workforce • Lack of affordable housing • Death of a spouse • Separation/divorce • Alcohol use disorders and acquired or alcohol related brain injury • Poor health or serious illness, often resulting directly or indirectly from abuse41 Women experiencing primary homelessness remain largely invisible among the homeless population. On the street they are exposed to high levels of violence, and there is a degree of shame associated with homelessness for many women, particularly older women who have never experienced, or ever expected to be in this situation42. They are therefore much more likely to be found couch surfing or sleeping in their car but are nevertheless experiencing primary homelessness.

37 See , Ending and Preventing Older Women’s Experiences of Homelessness in Australia, July 2015 38 McFerran, L. It could be You, Female, Single, Older and Homeless, A Report for Homelessness NSW and Older Women’s Network NSW, 2010 39 Doing it Tough, Brisbane and Council of the Ageing (COTA) Queensland, and Urbis 2015 40 There is a growing body of literature that documents how financial insecurity is leading to homelessness for many older single women, however the focus of this report is not so much on the reasons for homelessness for for this cohort, but rather on the barriers they may experience in accessing primary health services 41 Homelessness Australia, Homelessness and Older People, 2016 42 Mercy Foundation, Older Women’s Pathways out of Homelessness in Australia, 2014

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The Commonwealth Department of Health reports that women who are homeless are less likely than other Australians to use preventive and routine health care but are higher users of hospital emergency services, which often become the main point of access to health care.43 Because of their reproductive capacity women who are homeless have special needs when accessing primary health care and report that gaining access to tampons and pads when menstruating is a particular issue.44 These are the most requested item by women at homeless shelters. It is possible to make assumptions that some if not all of the barriers to accessing primary health care experienced by males would also apply to women, however the few studies that do exist suggest that gender and age are likely to result in additional barriers. As domestic and family violence rates and housing costs continue to rise, and as the gender pay gap continues to affect women’s earning potential it is clear that the rates of primary homelessness amongst women will also continue to rise. Removing access barriers to primary health care for women who are homeless needs to be given particular attention by researchers and service providers.

Young People Youth homelessness is one of the biggest problems facing Australia. Current statistics show that almost half of all people who are homeless are less than 24 years of age, with estimates for youth likely to have been underestimated in the Census due to a usual address being reported for some homeless youth.45 Other reasons for a potential underestimation of the numbers of young people who are homeless include the ‘hidden nature’ of their homelessness. This may be because they are staying temporarily with friends, couch surfing or in temporary accommodation. , the peak national youth homelessness body points out that many young people first experience homelessness by staying at their friend’s place one day and sleeping rough the other day. They don’t identify themselves as being homeless often not seeking support straight away until all support from family and friends has been exhausted. Young people can be both physically and socially vulnerable and generally lack skills in independent living. Rough sleeping only adds another layer to that vulnerability.

43 Department of Health, Development of a New National Women’s Health Policy, Consultation Discussion Paper, 5.2.3 Barriers to Accessing Health Care, Australia 2009 44 Vora, S., No More Taboos, The experiences of menstruation by homeless women: a preliminary report, 2016 45 Australian Bureau of Statistics, 2049.0 - Census of Population and Housing: Estimating homelessness, Factsheet: Youth homelessness, 2011

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Research has shown that people who first experience homelessness at a young age are more likely to experience persistent homelessness in adulthood 46, it is therefore important to focus on both prevention and rapid early intervention with this group, particularly for young people leaving out of home care and protection systems as they are especially vulnerable to becoming homeless47 Citing Rosenthal et al (2006) Yfoundations estimates that 70% of young people experiencing homelessness left home to escape family violence, child abuse or family breakdown48. ’s recently published report on ‘Youth Mental Health and Homelessness’ identifies concerns about family conflict, depression, coping with stress and suicide as the key reasons why young people become homeless or spend long periods of time away from home. Other reasons include exiting state care, unemployment, intergenerational poverty or severe overcrowding/housing crisis. Young people experiencing homelessness are very vulnerable, with:

• more than 90 per cent have witnessed violence in their home

• 60 per cent have been in out-of-home care

• more than 50 per cent have mental health conditions.49 Within the population of homeless youth there are several sub-groups including Aboriginal and Torres Strait Islander young people, young people from a CALD background and lesbian, gay, bisexual, transsexual, intersex and queer (LGBTIQ) young people. These young people, in addition to their homelessness often also experience discrimination and bullying, both in the general population and in the homelessness population, and face additional barriers when attempting to access services50 51 52. Barriers to accessing services identified in the literature include53 • Awareness of the existence of servicers • Significant wait times for services requested • Exclusionary practices by staff

46 Scutella & Johnson 2012 cited in Housing outcomes for groups vulnerable to homelessness, AIHW,1 July 2011 to 31 December 2013 47 Ibid. 48 Rosenthal et al. 2006. Why do homeless young people leave home? Australian and New Zealand journal of public health 30.3 281-285, 2006 49 NSW Government, Premier’s Priorities on Youth Homelessness, July 2017 50 Dunne et al, Young gay, homeless and invisible: a growing population? Culture Health and Sexuality, vol4, No.1, 103-115, 2002 51 Uhrig SCN, An Examination of Poverty and Sexual Orientation in the UK, 20 December 2013 52 Robards et al, Access 3: young people's healthcare journeys, Preliminary Report 2017 53 These were not all identified as barriers to accessing to primary health care services but there is no reason to suggest that they do not apply equally or even more to young people who are homeless as they do for other groups of people experiencing primary homelessness.

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• Physical environment of the service • Location of the service • No Medicare cards • Cost of transport and cost of service.54

The Access 3 study undertaken by the Department of General Practice, Sydney Medical School Westmead, The University of Sydney, in partnership with The University of Technology Sydney and NSW Health, explored access barriers to health services experienced by marginalised youth. Young people who were homeless and at risk of homelessness were included as one of the marginalised groups.55 Homeless youth represented 8.3% (118) of the total number of young people who completed the survey (1416). The report provides rich and recent data on the barriers experienced by marginalised young people in accessing health care. Although homeless young people were identified as a separate category, most of the report’s findings regarding barriers to the access of health care grouped all the young people together so it was not possible to identify the extent to which barriers for young people experiencing primary homelessness, or even homeless youth generally differed from other marginalised groups.

People who are Older and People Living with a Disability This project has not specifically focused on people who are older or people living with a disability. However, it is acknowledged that people from these two disadvantaged groups may already be included in the groups discussed above. As reported in the Homelessness Australia56 factsheet: Homelessness and Older People: ‘People over 55 are much more likely to access the hospital system and data shows that 64% of people living on the street are at risk of death within 5 years’. This is a priority area for further research. The Homelessness and Disability factsheet states: ‘Until recently there has been a lack of information about the relationship between homelessness and disability or the incidence and prevalence of homelessness amongst people with disabilities.’ The factsheets are based on 2011 Census data, with the release of the 2016 Census data having the potential to define the direction for the Intersectoral Homelessness

54 See Gronda, H. and Foster, G. Evidence to define youth focused homelessness practice, AHURI Research Synthesis Service, 2009 55 Robards et al, Access 3: young people's healthcare journeys, Preliminary Report 2017 56 Homelessness Australia factsheets available at: www.homelessnessaustralia.org.au/fact-sheets

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Health Strategy group to engage and develop policies with, and for these two at risk groups. It is also understood that there is a general lack of understanding or knowledge of the National Disability Insurance Scheme (NDIS) and that it is difficult for people living with a psychosocial disability who are experiencing homelessness to access the scheme. As reported in the Mind the Gap Report: ‘There is no funding for assertive outreach in order to engage and inform these hard-to-reach, yet most likely to meet NDIA eligibility criteria, people.’ 57

57 Mind the Gap: The National Disability Insurance Scheme and psychosocial disability Report, pg. 12 http://sydney.edu.au/health-sciences/documents/mind-the-gap.pdf

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CHAPTER 6. OPPORTUNITIES TO ENHANCE PRIMARY HEALTH CARE DELIVERY

People with the greatest vulnerabilities are the most disadvantaged in relation to access and engagement in health care. GPs and allied health practitioners have a pivotal role in coordinating care between different health care providers and parts of the health system. Through a review of the literature, consultations with key service providers and people experiencing homelessness, a range of opportunities were identified to address barriers to care and enhance primary health care delivery. • Equip GPs, allied health practitioners, reception and administrative staff with the skills, knowledge and confidence to build trust with people experiencing homelessness through targeted training and mentoring programs • Enhance communication between primary health care and acute services through standardised referral processes and assertive follow up of referrals • Refine protocols and mechanisms for sharing of health data across primary health care and acute services, to support the provision of holistic, integrated care (see BrisDoc for a good practice international example58) • Enhance connections between primary health care providers and community managed organisations so that health and welfare service providers can work together to ensure people experiencing homelessness receive appropriate support to attend medical appointments and follow treatment plans • Enhance primary, secondary and tertiary prevention approaches to people experiencing homelessness, recognising the range of health issues for which they are at high risk. This includes provision of vaccinations, screening for asymptomatic conditions and prevention of complications of existing health conditions.59 • Build workforce capability to provide trauma informed care • Expand existing models of service provision, including after-hours access to health care in locations targeted to people experiencing homelessness.

NEED 5: After hours assertive outreach primary health care services

58 A pilot scheme to help homeless people in Bristol called "BrisDoc Homeless Health Service" has been set up to allow access to the records of the transient population with often complex medical needs where ever the person appears. Sharing data has been made possible by combining information from two main systems – the Emis data-sharing platform used by 106 GP practices in Bristol (covering about one million patients) and Connecting Care, an electronic patient record allowing health professionals in Bristol, South Gloucestershire and North Somerset to access online NHS patient information. https://brisdoc.co.uk 59 www.racgp.org.au/your-practice/guidelines/greenbook/prevention-in-general-practice/what-is- prevention/

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CHAPTER 7. GOOD PRACTICE PRIMARY HEALTH CARE SERVICES FOR PEOPLE EXPERIENCING PRIMARY HOMELESSNESS

Characteristics of Good Practice Services The issues and barriers faced by people experiencing primary homelessness in accessing mainstream primary health care services are well recognised in the literature60 61 62. They were also confirmed through consultations undertaken for this project. However, there is less published evidence for what constitutes a ‘good practice’ in primary health care services for people experiencing primary homelessness. To some extent it is possible to make some logical assumptions about what constitutes good practice from what is already known about services that people experiencing primary homelessness elect not to use. As an example, it is reasonable to assume that good practice services would have addressed at least some of the services with high entry barriers (e.g. the need for a Medicare card, transport costs, lack of respect and understanding by service provider, seeing a different person each time etc.) Acknowledging the need for more evidence, following the consultations with service providers63 and with people experiencing primary homelessness, a literature review, and the observation of a range of different models of primary health care service delivery undertaken for the Project, the following characteristics have been identified as representing good practice in primary health care for people experiencing primary homelessness. While service models differ, there are some fundamental good practice characteristics that appear to apply across all service models. These include: • Individual focus – an ability to understand and adapt to the often ‘chaotic’ lives and unpredictable behaviour of people experiencing primary homelessness • Safe environ – the provision of an environment where people feel safe, do not feel judged, can consistently see the same person and develop trust with that person • Common entry points, and entry access barriers that are as low as it is possible to safely make them

60 Day C, Ross J, Dolan K. Hepatitis C-related discrimination among heroin users in Sydney: drug user or hepatitis C discrimination? Drug Alcohol Rev, 22:317–21, 2003 61 Richard L, et al Equity of access to primary healthcare for vulnerable populations: the IMPACT international online survey of innovations, International Journal for Equity in Health The official journal of the International Society for Equity in Health15:64, 2016 62 Meyer BS, et al. Inequities in Access to Healthcare: analysis of national survey data across six Asia-Pacific countries. Health Serv Res. 2013; 13:238 63 Consultations with service providers included both homelessness service providers and primary health service providers for people experiencing primary homelessness

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• Collaboration with other services - with homelessness services, services providing assertive outreach and government agencies • Having clear referral pathways • Shared common protocols and practices where appropriate e.g. common high-quality assessment and referral processes and protocols • Ability to share information (with individual consent to minimise client frustration in repetition of their ‘story’ and duplication of services • Provision of multidisciplinary primary health care services in the one location e.g. medical, dental, nursing, counselling • Assertive outreach teams with multidisciplinary providers • Continuity of care especially with exit, discharge and ongoing care • Services that are available after hours • Embedded primary health care workers in homelessness services • Address the needs of population subgroups within the population of people experiencing primary homelessness.

Models of Service Delivery Good practice service characteristics are not restricted to one particular model of service delivery. There is not a service model that will meet all individuals’ health care needs. Good practice characteristics exist in fixed and mobile outreach models, and in place based clinical models although they will differ in terms of factors, such as access barriers (e.g. location, cost, documentation required, type of services provided64), collaboration with other parts of the health system, or with relevant homelessness services etc. Shortt et al65 undertook in Canada one of the few evaluations of different primary health service models for people who are homeless using good practice criteria such as patient centeredness, access, strengthening the quality of primary health care, and promoting continuity through integration and coordination. The evaluation identified four models of care. 1. Status quo - GP and AHS practices 2. Standard facilities or clinic sites exclusively dedicated to serving homeless people 3. Fixed (in situ) outreach model

64 For example, whether the model provided multidisciplinary health services, or had a more limited health service such as ‘mainstream’ mental health clinics or dental clinics. 65 Shortt et al, Primary Health Care for Homeless Persons: Evaluating the Options Using a Policy Analysis Approach, 2010

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4. Mobile outreach service model

The evaluation findings demonstrated that the status quo performed poorly on all but one of the 13 evaluation criteria. The other three models, while demonstrating individual differences, performed well overall. The authors concluded that, on the specified measures used in the evaluation there are factors other than performance that should be taken into account when choosing a model of care. Primary health services that are likely to be successful in both improving the immediate health of service users and, in the longer term, reducing primary homelessness need to consider all the health care and homelessness factors and a ‘system that incorporates “vertical equity,” that is, the capacity to meet unequal needs with unequal resources’ (cited page 12).

Examples of Local Good Practice Good practice service delivery is not restricted to one service model. Across the CESPHN region there are a number of different service models that incorporate good practice service delivery. Several different service models were identified as examples of local good practice: 1. Kirketon Road Centre 2. St Vincent’s Homeless Health Service 3. The Wayside Chapel 4. Youthblock While they are each different service models, they demonstrate many of the good practice characteristics identified above especially the non-discriminatory, trust based and individual focussed approach to meeting support and health care needs. As well as maximising the potential for positive outcomes for service users, adhering to good practice also facilitates access for the person experiencing homelessness. Consultations with individuals regarding services they used when needing medical attention confirmed, at the very least, their preference for and use of those services where: • They would not be discriminated against and were treated with respect • Seeing the same practitioner allowed a relationship of trust to be built • They did not have to have a Medicare card • Entry barriers were low e.g. they did not have to make appointments or wait in environments where there were no other homeless people e.g. GP surgery • The service was available after hours.

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The data on use of good practice services gained from the consultations with individuals and with consultations from health workers was confirmed in the literature.66 Often people would use different services. For example, people who use a homeless service such as the Wayside Chapel for meals, showers or for social purposes would also use the service to access the GP or nurse. However, if the practitioner’s workload was heavy on that day and the wait was too long, people would then either go to St Vincent’s Hospital Emergency Unit or to the Kirketon Road Centre. These services are all in close proximity and meet the relevant best practice criteria identified above. This pattern of identifying and using a limited number of services that demonstrate good practice was also identified in the literature.67 In March 2016, SESLHD held a consumer consultation workshop which aimed to provide insight into the experiences of those who have recently experienced homelessness.68 Key issues raised by participants included: • Health services are complex to access • There is a need to raise awareness amongst health workers about homelessness and the services available • The Aboriginal Medical Service provides a good model of service delivery - “they have a great name across the sector” • “True” outreach models of service delivery are required • People experiencing a mental health crisis require a health intervention in the first instance rather than a police intervention • A comprehensive health care plan is required for people leaving hospital to avoid another crisis and return to hospital • Tailored models of service delivery are required to provide access to a range of health services • Client mobile phones are the best way keep in touch. Apps and internet are not as highly valued because a ‘smart’ phone is needed, and computer information is not actively sought • The closure of the Haymarket Foundation Clinic was seen as a big problem.

The StreetCare Homelessness Heath Consultation Workshop provided information into the experiences of people who have recently experienced homelessness. The report proposed strategies that promote ease of access to the health system as a whole, the viability of co-location models with key services and the need to develop a

66 Keogh et al, Health and use of health services of people who are homeless and at risk of homelessness who receive free primary health care in Dublin 2015 67 See for example Brodie et al, Rough Sleepers: health and healthcare, NHS, February 2013 68 SESLHS, 2016, StreetCare Homelessness Heath Consultation Workshop report

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comprehensive approach to the planning and provision of continuity of health care for people leaving health facilities. Finally, those health services for people experiencing primary homelessness that align their service delivery with good practice also generate an economic benefit for the health system, as well as improved health outcomes for individuals. A recent independent evaluation of St Vincent’s Hospital’s Homeless Health Service demonstrated that even where a substantial investment of resources up-front was required, ‘appropriate and tailored health care for homeless people can reduce their reliance on the hospital system for their health care and deliver significant cost savings in the short-medium term. 69 The evaluation of the St Vincent’s Homeless Health service also confirmed its effectiveness in improving the health status and health service access of people who are homeless over time and in reducing the use of the emergency department. See Appendix D for further information on each of the service models.

Orange Sky mobile laundry – photo The Daily Telegraph 16 May 2017

69 Conroy et al, St Vincent’s Hospital’s Homeless Health Service: “Bridging of the Gap” between the Homeless and Health Care, St Vincent’s Research Bulletin, August 2016

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CHAPTER 8: DISCUSSION AND CONCLUSION

Primary homelessness is a challenging social problem. Despite extensive efforts at the local national and international level, the number of people experiencing primary homelessness continues to rise. Universally it is recognised that the majority of people experiencing primary homelessness are a complex cohort. Many have experienced extensive trauma in their lives and as a result experience mental health problems and/or frequent substance use. People’s lives can often be chaotic and behaviour may be unpredictable. With respect to health, many people experiencing homelessness often present with co or tri- morbidities. Addressing health issues is not necessarily the utmost priority for people. Securing shelter, safety and even the next meal are often much more important. For all of these reasons the provision of ‘fit for purpose’ primary health care services and/or the identification of evidence-based strategies that facilitate access to primary health care can be challenging. Given the degree and the complexity of health problems people who experience primary homelessness have, and that, at any age, they may be ‘rough sleeping’ for long periods, ensuring that they are able to maintain the best possible health through access to appropriate primary health care, is important. It is also important to emphasise that people experiencing primary homelessness are a diverse group. Just like the broader society they are young and old, Aboriginal and non-Aboriginal, they are from different cultural backgrounds, they are male and female and gender diverse. They have different needs and they face different barriers when attempting to access primary health care services. There will be no one system or service model that will provide access to all. The capacity to ensure that sufficient fit for purpose services exist across the CESPHN will require leadership and integration, governance and resources at the systems level. It will also require capacity building and greater coordination at the service level and will require education and support at the ‘practitioner level’. There is also a need for much greater collaboration between primary health care services and homeless services especially assertive outreach services. There needs to be a ‘Homeless Health Pathway’ that sets out the linkages between primary health and homelessness services and ensures that there is sufficient support provided so that necessary health treatments are maintained and the person does not end up on the street once again because they have not attended appointments or adhered to their treatment plan The research undertaken for this project indicates that across the CESPHN Region there are opportunities to improve system integration, develop new or replicate current good practice service models, develop new programs such as education and training for GPs and practice staff. There are also opportunities to make changes in and improvements to current services that will improve access to primary health care, such

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as standard referral protocols, online platform of information, better communication and collaboration between systems and services, between mainstream services and specialist health services, GP and allied health services. The recommendations on page 7 of the Report were drawn from the results of the research undertaken for this Project, consultations with individuals, General Practitioners, allied health practitioners, community managed organisations, Local Health Districts and discussions with members of the Project Advisory Group.

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Sydney Health Community Network - Enhancing the Primary Health Care Needs of People 44 Experiencing Homelessness in the CESPHN Region Report

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Additional Reading

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Australian Government, National Mental Health Commission www.mentalhealthcommission.gov.au

Australian Human Rights and Equal Opportunity Commission, 2008 Homelessness is a human rights issue, www.humanrights.gov.au/publications/homelessness-human-rights-issue#5

Birdsall-Jones C, Corunna V, & Turner N, Indigenous Homelessness, Research Bulletin, Issue134, ISSN 1445-3428, p.1, December 2010

Black, C, & Gronda, H, 2011, Evidence for improving access to homelessness services, the Australian Housing and Urban Research Institute (AHURI), July

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Commonwealth Budget 2017, Fact Sheet 1.7 A new National Housing and Homelessness Agreement

Cooper, K, 2017, Wicked Problems: what are they, and why are they of interest to NNSI researchers? Network for Non-profit and Social Impact, Northwestern University School of Communication

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Erny-Albrecht. K. & Bywood, P. ‘Barriers to primary health care access—an update, Expert Plus’, March 2016

Sydney Health Community Network - Enhancing the Primary Health Care Needs of People 46 Experiencing Homelessness in the CESPHN Region Report

Fine, M., Pancharatnam, K. & Thomson, C. Coordinated and Integrated Human Service Delivery Models, Social Policy Research Centre, University of NSW, available online https://www.sprc.unsw.edu.au/media/SPRCFile/Report105 Coordinated Human_ Service Delivery Models.pdf 2000, [Accessed 4July 2017]

Flatau P., Conroy, E., Thielking, M., Clear, A., Hall, S., Bauskis, A. & Farrugia, M., 2013 How integrated are homelessness, mental health and drug and alcohol services in Australia? Australian Housing and Urban Research Institute, Final Report No. 206, May, 2013

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Appendix A – Existing Primary Health Care Services in CESPHN Region

Table A: Targeted Primary Health Care Services Service Organisation Partners Service Type Comment Clinic based Outreach Kirketon Road Primary ü ü Centre Integrated & Community Health, SESLHD

Homeless St Vincent’s Wesley Mission ü Health Hospital Neami National Service Network

Table B: Primary Health Care Clinics in Community Managed Organisations Service Organisation Partners Service Type Comment Clinic Outreach based Special Oral Health Mission Australia ü Needs Dental SESLHD Centre Service Matthew St Vincent de HARP Unit, SESLHD ü Funding Talbot Health Paul received Clinic through NSW Health NGO Grants, SESLHD. Mission St George Mission Australia ü Australia GP Hospital, SESLHD Centre and Nurse Clinic Exodus GP SLHD Exodus ü Clinic and Foundation Dentist

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Table C: Other Community Managed Organisations providing health information, support and referrals for people experiencing homelessness Service Organisation Description Comment

Asylum Asylum Seekers Health care assessments, medical and oral Funding Seekers Centre health consultations, torture and trauma received Centre Clinic counselling, physiotherapy, referrals, through NSW education and advocacy Health NGO Grants, SLHD

Bourke Street The Haymarket Post-detox residential rehabilitation living Funding Drug & Foundation skills program for people over 18 years. received Alcohol through NSW Project Health NGO Grants, SESLHD Camperdown Mission Australia Long-term housing for homeless people and Funding Common people on low incomes in the inner city of received Ground Sydney. through NSW Project Health NGO Grants, SLHD

Community Wayside Information, advocacy and referral to Funding Service Chapel people who are marginalized or received Centre disadvantaged. Most common referrals are through NSW Project to accommodation services, primary health Health NGO care, mental health support, alcohol and Grants, SESLHD other drugs rehabilitation and detoxification.

Drop-In The Station Drop in service for homeless and Funding Service at the unemployed men and women adversely received Station affected by alcohol and other drugs, through NSW and/or mental illness; provides individual Health NGO counselling, referral and facilitation of Grants, SESLHD outreach health and other services to individuals. HIV/AOD The Haymarket Integrated service provided in partnership Funding Integrated Foundation with the Bobby Goldsmith Foundation, for received Services people with HIV who have complex needs through NSW Project including needs arising from alcohol and Health NGO other drugs and/or mental health problems Grants, SESLHD that place them at risk of homelessness.

Youth Wayside Outreach and fixed site service providing Funding Services Chapel information, assessment and referral for received Project youth at risk of alcohol and drug related through NSW harm in the Kings Cross area. Health NGO Grants, SESLHD

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Table D: Mainstream Health Services whose target groups include a high percentage of people experiencing homelessness Service Organisation Description

Redfern AMS Provides culturally appropriate health care to Aboriginal and Aboriginal Cooperative Torres Strait Islander people and communities. Medical Service

HIV Outreach HARP Unit, Multidisciplinary team of nurses, dietitians, social workers and Team SESLHD an occupational therapist which provides confidential health care services for people living with, or closely affected by HIV across SESLHD.

Drug and SESLHD Services include: Alcohol The Langton Centre Services St George Hospital Drug and Alcohol Service Sutherland Hospital Drug and Alcohol Service Drug and Alcohol Population and Community Programs Unit Mental Health SESLHD Services include: Services Eastern Suburbs Mental Health Service St George Mental Health Service Sutherland Mental Health Service

Drug Health SLHD Services include Withdrawal Management, Stabilisation, Opioid Services Treatment, and Magistrates Early Referral into Treatment program (MERIT) Harm Minimisation, including Needle Syringe Program, Counselling, Perinatal and Family Drug Health Services and Hospital Consultation and Liaison.

Mental Health SLHD Provides integrated inpatient and community mental health Services clinical services through a clinical stream across the Sydney Local Health District. Inpatient services are provided at Concord, Royal Prince Alfred and Thomas Walker Hospitals. The community mental health services are provided at Redfern, Camperdown, Marrickville, Canterbury and Croydon.

Youthblock SLHD Specialist service providing multidisciplinary, primary health Youth Health care support to young people, including an on-site drug and Service alcohol nurse practitioner. Focusing on engaging disadvantaged young people, both on-site and in outreach.

Sydney SLHD Community Oral Health Clinic Dental Hospital

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Appendix B – Policies and Legislation

Table E: Summary of current policies and legislation addressing homelessness COMMONWEALTH DATE POLICY / LEGISLATION 1994 Supported Accommodation Assistance Act 1994 1995 Supported Accommodation Assistance Program (‘SAAP’) 1996 The Housing Assistance Act 199670 2008 The Road Home (Commonwealth White Paper) 2009 The National Partnership Agreement on Homelessness (NPAH) renewed annually until 2017 2009 National Affordable Housing Agreement (NAHA) – replaced SAAP 2018 onwards National Housing and Homelessness Agreement (NHHA) – replaces NAHA and combines funding for NAHA and National Affordable Housing Specific Purpose Payment (NAHSPP). Includes additional funding for frontline services to address homelessness STATE 2009 - 2018 Homelessness Action Plan 2016 ‘Foundations for Change – Homelessness in NSW’ Discussion Paper 2016 NSW Strategic Plan for Children and Young People 2017 FACS response to the Discussion Paper in progress 2017 Additional $20m for access to transitional housing for rough sleepers rough and others experiencing homelessness 2017 - 2019 Premier’s Priority on Youth Homelessness 2017 - 2024 NSW Youth Health Framework LOCAL GOVERNMENT 2003 Sutherland Shire Council Homelessness Policy 2007 - 2012 City of Sydney Homelessness Strategy 2017 Inner West Council Homelessness Policy - draft

70 Amendments to the Act were made in 2009 in keeping with the National Partnership Agreement on Homelessness

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Appendix C – Regional Registry Week Data 1. Inner City Sydney Registry Week 2015 Across the CESPHN region it is the City of Sydney LGA that has by far the largest number of people experiencing primary homelessness. A Street Count, which began in 2008 of ‘rough sleepers’, is undertaken twice a year – once in summer (February) and once in winter (August) between the hours of 0100 and 0300. The numbers of people experiencing homelessness who are staying in crisis accommodation hostels is also recorded.

February 2016 saw the numbers of people sleeping rough at an all-time high of 486 with crisis accommodation services 98% full. In February 2017, there was a reduction in people sleeping rough at 433, however a further 489 people occupied crisis and temporary accommodation beds and 26 occupied hospital beds.

The Inner City Sydney December 2015 Registry Week surveyed 516 people experiencing homelessness.71 Participants identified having many and multiple interactions with the NSW health system. In total participants identified over the past 6 months, 376 periods of hospitalisation, 1007 visits to the emergency department and 527 trips taken in an ambulance. Data also highlights the ongoing mental health and substance abuse issues faced by people experiencing primary homelessness. Of the surveyed participants:

Physical Health Condition # Respondents Percentage Asthma 129 25% Dental problems 276 53% Diabetes 49 9% Emphysema 58 12% Heart disease or Arrhythmia 82 16% Hepatitis C 136 27% Kidney disease 33 7% Liver disease or Cirrhosis 74 15%

Physical health 25% reported experiencing Asthma (n=129) 9% reported Diabetes (n=49) 27% reported contracting Hepatitis C (n=138) 7% reported Kidney disease (n=33) 12% indicated a diagnosis of Emphysema (n=58) 9% reported of having cancer (n=42)

71 Homelessness NSW Inner City Sydney Registry Week 2015 Report

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3% reported a diagnosis of HIV/AIDS (n=15) 15% reported a Liver disease or Cirrhosis (n=74) 16% reported Heart disease or Arrhythmia (n=82) 53% identified having dental problems (n=276) Alcohol and other drug use 36% reported using intravenous drugs (n=185) 37% report using alcohol daily for 30 days straight (n=193) 72% reported substance abuse (n=372) Mental health and disability 53% reported seeing a professional about a mental health issue in the last 6 months (n=276) 26% reported a diagnosis of a learning development or developmental disability (n=130) 29% reported having a brain injury (n=149) 20% indicated that they had a permanent physical disability that limits their mobility (n=101) Of people experiencing a mental illness: 64% have both substances abuse and mental health issues (n=330) 47% report experiencing comorbidity of mental ill health, substance use and a significant medical problem (n=237) Trauma Registry data also reveals the role of trauma in causing and sustaining homelessness. Of participants: 49% of people reported experiencing emotional, physical, psychological, and sexual or other abuse prior to become homeless. Another 34% (n=121) identified having self-harm while being homeless. Significantly 34% (n=121) of participants reported a history of being in foster care Interactions with the justice system Participants reported high levels of interaction with the criminal justice system. Over 53% of respondents indicated that they had been in prison (n=272), 65% that they had been arrested (n=335) and over 44% indicating had been a victim of violence while homeless Significantly, survey respondents reported over 9,200 interactions with police in the last six months.

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Data Groupings The data are then further analysed on the basis of major groupings. These groupings are listed, making mention only of the conditions most prevalent (over 40% of the sample) in each group reported, as the sample sizes of each grouping are small. Aboriginal and Torres Strait Islander people (17%) over represented 42% reported living with Hepatitis C (n=36) 61% identified having dental problems (n=52) 54% reported using intravenous drugs (n=46) 54% report using alcohol daily for 30 days straight (n=46) 77% reported substance abuse (n=65) 61% reported having a brain injury (n=52) 55% of people reported experiencing emotional, physical, psychological, and sexual or other abuse prior to become homeless (n=47). Women 61% identified having dental problems (n=53) 53% reported substance abuse (n=46) 52% reported a mental health issue (n=45) 45% had been victims of violence/physically assaulted while experiencing homelessness. Young People 54% reported substance abuse (n=19) 42% reporting being diagnosed with a learning or development disability (n=15) 45% of people reported experiencing emotional, physical, psychological, and sexual or other abuse which they identify as causing their homelessness Older People (over 55) 44% identified having dental problems (n=33) 43% reported substance abuse (n=32) Veterans 78% identified having dental problems (n=33) 60% reporting substance abuse (n=25); 48% reported seeing a professional about a mental health issue in the last 6 months (n=20) 58% reported experiencing emotional, physical, psychological, and sexual or other abuse which they identify as causing their homelessness.

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2. Waverly LGA Registry Week 2016 The initial Waverley Registry Week was undertaken between 12 - 14 April 2016. Numbers were far smaller than for the inner city (n=41) but nevertheless revealed similar findings. Most participants (n= 38/ 93%) were over 25 years of age. The average age was 45 years (rounded) and the average length of time being homeless was 5 years.

Most Frequently Slept # Respondents

Rough sleeping 26 Emergency/crisis accommodation 8 Temporary accommodation 3

Friends/Family/Other 4

Health Status # Respondents (Rough Sleepers N=26)

Tri-morbidity 11 Liver disease 4 Alcohol daily for 30 days 13 Intravenous drug use 7 3 x ED or hospital last 6 months 9

3 x ED last 6 months 5

Length of time homeless and average age:

Total surveyed 41

Average age 44.6 years Average time homeless 5 years

Average time homeless (one outlier removed) 4.2 years

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3. Sutherland Shire LGA Registry Week 2016 In 2016 Sutherland Shire undertook an initial Registry Week survey. Thirteen people were surveyed. Of those 13 people: • 12 were sleeping rough (i.e. in bush land, cars, park, tent) • Average time homeless was 2.2 years • Longest duration of time homelessness was 25 years • Shortest time was 3 months • 8 of the 13 had not been in secure accommodation in the last 3 years • The majority was male, non-Indigenous and on a disability pension • Youngest was 40

Health Status # Respondents (Rough Sleepers N=26)

72 Vulnerable 8 Heat stroke 5 Trauma (not sought help) 7 Attack victim 5 Mobility limits 5 Dental problems 10 Learning or developmental disability 4 Substance use 8 Mental health condition 7 Any serious health condition 7

Cost to the Health System – over $100K in 6 months (average 410k per person)

Health Service Average Total times Total Cost (Feb to Aug 2015) times Hospital admissions 1.5 19 $ 88,844 ED visits 2.6 34 $ 38,352 Ambulance transports 1 13 $ 8,450 TOTAL $ 135,646

72 ‘Vulnerable’ refers to individuals with the presence of one or more of the following indicators: 3 or more ED or hospital admissions in 6 months, 60yrs or older, HIV+/AIDS, liver disease, kidney disease, or wet weather injuries, alcohol daily for 30 days; and 6 or more months homeless.

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Appendix D - Examples of Local Good Practice

Kirketon Road Centre – Integrated Primary Health Care for People Experiencing Homelessness

The Kirketon Road Centre (KRC) in Kings Cross was established in 1987 and is funded and coordinated by the South Eastern Sydney Local Health District. It is an integrated targeted primary health care centre that provides comprehensive primary health care for a wide group of people who are marginal and at risk. KRC has a population focus rather than a disease-specific focus, in keeping with a holistic approach to the provision of its services. KRC operates outside of the Medicare arrangement and uses an anonymous registration system that does not require verification of personal identification. This system ensures confidentiality of individual consultations to a level beyond the standard confidentiality of health information requirements in Australia. Together with its non- discriminatory, non-clinical setting and atmosphere, this facilitates and supports access by people experiencing primary homelessness. KRC employs a full time clinical nurse consultant specialising in homelessness and runs outreach clinics and accommodation services such as Edward Eagar Lodge. The Centre sees up to 70 people per day for issues that include sexual health (34%), drug and alcohol (14%), HIV and hepatitis (9%), counselling/psychosocial services (25%) and general medical care (18%). Over one third of people who attend for alcohol and other drugs or hepatitis services at KRC report homelessness. KRC also operates Clinic 180, which is open on evenings and weekends. Clinic 180 provides a range of range of additional nurse-led clinical services targeting high-risk hard-to reach population groups who do not access more traditional health services during normal business hours. In addition to KRC’s youth outreach services Clinic 180 also has a focus on marginalised youth including young people who are homeless or at risk of homelessness. KRC also provides education and training programs and annually delivers a primary health care and outreach training program.

Sydney Health Community Network - Enhancing the Primary Health Care Needs of People 57 Experiencing Homelessness in the CESPHN Region Report

St Vincent’s Homeless Health Service – Inner City Assertive Outreach and Care Coordination for Vulnerable and Complex People

This outreach service for people experiencing primary homelessness is a partnership between Way2Home, Neami National, the City of Sydney, FACS/Housing NSW, St Vincent’s Homeless Health Service and community managed organisations such as Innari Aboriginal Service and Missionbeat. Way2Home is an assertive outreach service operated by Neami National and St Vincent’s Hospital that is co-funded by the City, has supported 189 people who were previously chronically homeless in the inner city into permanent housing. The service works with individuals with complex needs who are sleeping rough. Outreach workers directly engage with individuals on the streets, or wherever they are sleeping, offering assistance and care management. As discussed above assertive outreach is considered to be one of, if not the most effective ways of reaching and supporting people experiencing primary homelessness to access mainstream services including primary health care services. On outreach visits it was possible to observe the need for development of trust with people who are deeply traumatised and for whom trusting others is a major life challenge. As one Homelessness Health team member said “it might take 4 or 5 contacts with a person before they are prepared to tell you what healthcare they need”. This is clearly a resource intense activity, and may present challenges for government funders who, understandably will always attempt to achieve the most positive and sustainable outcomes in the shortest possible time. However, despite its resource intensity the assertive outreach model has many benefits for people experiencing primary homelessness. It has the capacity to meet immediate health care needs while supporting ongoing assistance for illnesses that require longer-term specialist or clinical care. Team members also participate in follow up care coordination meetings. At these meetings relevant information about individuals is shared in a safe private space with appropriate ethics protocols in place. This strengthens a coordinated care approach, facilitates effective follow up and reduces duplication and/or people ‘slipping through the cracks.’ The Homeless Health team also facilitates the integration of primary health care with other services e.g. housing wrap around support and provides opportunities to discuss accessing GPs in business hours thereby reducing attendance at emergency departments.

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The Wayside Chapel – Connecting Health, Homelessness and Housing

The Wayside Chapel, a non-government charity established in 1964 has become an important inner city hub that provides a range of services for people who are homeless or are at risk of homelessness. Basic services include meals i.e. breakfast and lunch, laundry and shower facilities, music, art, cooking, and fitness sessions as well as a range of services providing information about, and/or referral to housing, social services, employment or benefits etc. For the purposes of this project, and in terms of demonstrating good practice, the Wayside Chapel also provides a primary health clinic. The clinic is part funded through NSW Health NGO Grants, and administered through Homelessness Health Program, SESLHD. GPs and allied health workers from St Vincent’s Homeless Health and Doctors staff the primary health care clinic. In addition to the primary health clinic the Wayside Chapel also provides an outreach and fixed site service providing information, assessment and referral for youth at risk of substance use related harm in the Kings Cross area. This service is also part funded by the SESLHD. In an average week the Wayside Chapel will provide 741 instances of health-related support including in mental health. Wayside as a strong connection with health, housing, legal, employment, social Aboriginal and other service providers. Because of its ‘iconic’ status and its philosophy of community building without judgement, Wayside draws a diverse and a large number of homeless people. In this sense it provides both a gateway and a pathway for people who are homeless and who might otherwise not engage with a health service. The primary health service may or may not be the first point of contact at Wayside Chapel, as there are multiple entry points. Conversations with people engaged with the Wayside Chapel consistently emphasised feelings of safety, trust, lack of discrimination and judgement as the reasons for engagement with the service. This culture permeates the whole organisation and means that people often access the health clinic via a range of entry points.

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Youthblock – Youth Health Service

Sydney Local Health District manages Youthblock, providing free, safe and confidential support, counselling and health services for young people aged 12-25, including youth who are homeless. Services are delivered from the Youthblock sites in Redfern and Belmore and in nursing outreach clinics. Nursing Outreach Clinics - The Youth Health Nurse, doctor, and counsellors when needed, can provide in an outreach clinic the following services: • Holistic health assessment that includes: • Presenting problem • Home, family life, living arrangements, financial matters • Physical health including oral health, immunizations, and visual health • Mental health • Sexual and reproductive health, including screenings • Alcohol and other drugs • Care management • Support of identified health, and psychosocial issues including assistance with accommodation and finances • Health education workshops. YHUNGER - The NSW YHUNGER (Younger Hunger) program aims to improve food access and physical activity options for young people, 14-24 years old who are at risk or experiencing homelessness. A referral or Medicare card is not required and services are free. Youth Point - The Youth Point is a mobile website service directory designed to link young people with the most appropriate services nearest to them. The availability of the website using smart phone technology and aims to reduce barriers and facilitate access to services for young people, particularly youth who are most vulnerable. Data Collection - Youthblock is collecting data on the basic demographics of the young people that live in youth refuges across Sydney LHD that are accessing Youthblock nursing outreach clinics. These young people are homeless or at risk or homelessness or under the Out of Home Care program. Further information at: https://www.slhd.nsw.gov.au/research/department_details.html?research=youthblock For further information on Homelessness in SLHD see: www.slhd.nsw.gov.au/PopulationHealth/PHO_homelessness.html

Sydney Health Community Network - Enhancing the Primary Health Care Needs of People 60 Experiencing Homelessness in the CESPHN Region Report