SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW - A survey conducted by the Homelessness Action Group under the ...

 
SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW - A survey conducted by the Homelessness Action Group under the ...
SURVEY OF HEALTH SERVICES
  FOR PEOPLE WITHOUT SECURE HOUSING
                              NORTHERN NSW

A survey conducted by the Homelessness Action Group under the leadership of the North Coast NSW
              Alliance to Improve Services to Vulnerable Members of the Community
SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW - A survey conducted by the Homelessness Action Group under the ...
ACKNOWLEDGEMENT
The North Coast NSW Alliance to Improve Services
to Vulnerable Members of the Community (the
Alliance) appreciates the contribution of all the
members of the Homelessness Action Group.

                                                    DISCLAIMER

                                                    The Homelessness Action Group has taken
                                                    reasonable steps to ensure the information
                                                    contained in this report, Survey of Health Services
                                                    for People Without Secure Housing, Northern
                                                    NSW, August 2014, is accurate and up-to-date and
                                                    is not responsible for any errors or omissions in
                                                    the content and reserves the right to revise or add
                                                    to the content at any time without notice to you.

                                                    No part of this report may be reproduced,
                                                    transmitted, stored in a retrieval system or
                                                    adapted in any form or by any means (electronic,
                                                    mechanical, photocopying, recording or otherwise)
                                                    without permission of North Coast NSW Medicare
                                                    Local (NCNSWML).

                                                    RECOMMENDED CITATION

                                                    North Coast NSW Medicare Local, Survey of Health
                                                    Services for People Without Secure Housing
                                                    Northern NSW, August 2014

                                                    ENQUIRIES

                                                    Enquiries should be addressed to Manager,
                                                    Strategic Development and Program Design,
                                                    NCNSWML by emailing planning@ncml.org.au

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SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW - A survey conducted by the Homelessness Action Group under the ...
CONTENTS
                                                                                        Page

ACKNOWLEDGEMENT                                                                            2

EXECUTIVE SUMMARY                                                                          4

INTRODUCTION                                                                               6

BACKGROUND                                                                                 6

SURVEY DESIGN AND HOW IT WAS CONDUCTED                                                     7

FINDINGS OF THE SURVEY                                                                     8

      Sample of Respondents                                                                8

      Responses from the Homelessness and Community Services Sector                        8

      Responses from Services that are Primarily Health Care                              17

DISCUSSION                                                                                27

CONCLUSION                                                                                29

APPENDICES
      Appendix 1 – North Coast NSW Alliance to Improve Services to the Vulnerable         30

      Members of the Community Memorandum of Understanding
      Appendix 2 – Diagrammatic Representation of Alliance and Action Groups              33

      Appendix 3 – Homelessness Action Group Terms of Reference                           34

      Appendix 4 –Survey Questionnaire                                                    36

      Appendix 5 – Summary of Responses to the open ended questions                       46

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SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW - A survey conducted by the Homelessness Action Group under the ...
support services for people without secure
EXECUTIVE SUMMARY                                    housing. Of the 289 responses, 54.7% were
                                                     received from the health care sector and 45.3%
The Survey on Health Services for People without     from the homelessness and community services
Secure Housing, Northern NSW was conducted by        sector, representing a relatively even response
the Homelessness Action Group (HAG) which was        from the two sectors. Issues covered include
established by the North Coast NSW Alliance to       accessibility to health services, information
Improve Services to the Vulnerable Members of the    needed, problems encountered, communications
Community (The Alliance) in May 2014.                and suggestions for improvements. The open
                                                     ended questions provided opportunity for
The Alliance was established under a                 respondents to provide detailed information about
memorandum of understanding between                  barriers, challenges and solutions demonstrating
Northern NSW Local Health District (NNSWLHD),        the multi-faceted complexities in providing
the Department of Family and Community Services      effective health care.
(FACS) and North Coast NSW Medicare Local
(NCNSWML) in October 2013.
                                                     KEY FINDINGS
The Terms of Reference articulate a vision of
                                                     • Barriers to accessing health care include cost,
       “fostering a response to the needs              waiting times, transport, lack of services and
      of the vulnerable members of the                 lack of understanding about the health system
      North Coast community that is                    and fear of judgement.
      client centred, multi-sectoral and             • Inability to identify a home address made it
      is integrated and cohesive where                 difficult to secure appointments, particularly
      services are provided”. (See                     where these were notified by mail and also on
      Appendix 1)                                      the ability to provide outreach services.
                                                     • Agencies found some health care services
                                                       easier to work with than others, citing quality
The Alliance established the Homelessness Action
                                                       of service delivery, staff attitudes and
Group to
                                                       understanding of homelessness, accessibility,
                                                       communication and collaborative work
       “drive action and empower
                                                       practices as key to effective working
      people experiencing or at risk of
                                                       relationships.
      homelessness and those delivering
                                                     • Generally, only a small proportion of health
      services to facilitate change”(See
                                                       care services always provided agencies with
      Appendix 2).
                                                       sufficient and detailed information required to
                                                       assist clients.
                                                      • The survey highlighted a lack of clarity
The Survey of Health Services for People without
                                                         around ‘who to contact’. Communication
Secure Housing Northern NSW, was collaboratively
designed and widely distributed with the support         difficulties between agencies was a
of both the health and homelessness support              commonly identified and identified the need
services sectors. It was developed to better             for an improved mechanism to share
understand the barriers in the health sector for         information on
people without secure housing and the challenges               o clients and their healthcare needs
experienced by workers planning and delivering
                                                               o availability of support services and
care and support. The scope of the survey included
hospital inpatient and emergency services,                          pathways
community based services and primary health care               o access to emergency housing
services including general practice as well as a               o social workers or care workers who
wide range of agencies providing housing and                        could assist navigating the
other support to people without secure housing.                     healthcare or social housing sector.
                                                      • A consistent theme was the perception that
The survey was administered via the on-line survey
                                                         health services were not sensitive to the
tool, Survey Monkey. It comprised 26 questions
including 12 open ended questions directed at            trauma experienced by people without
informants from organisations that primarily             secure housing and didn’t understand the
provide health care services and those providing         problems they encountered. It was reported

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SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW - A survey conducted by the Homelessness Action Group under the ...
that this impacted upon the clients
     perception of being judged or discriminated
     against, and also the ability of healthcare
     workers to deliver effective client centred
     health care.

The survey provides an indicator of the difficulties
faced in accessing and delivering healthcare
services for people without secure housing. It will
shape the work of the HAG, identify areas for
further consultation and inform the development
of a regional action plan to improve health care
services to people without secure housing. It also
provides a base line to monitor progress over time.
It is hoped it will inform the work of other agencies
in the region and provide the catalyst for further
discussion and investigation.

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SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW - A survey conducted by the Homelessness Action Group under the ...
from the health and homelessness and community
INTRODUCTION                                          services sectors. (See Appendix 3)
This report has been compiled under the               The Homelessness Action Group quickly identified
leadership of the North Coast NSW Alliance to
                                                      the limited data relating to homelessness and in
Improve Services to Vulnerable Members of the
Community (the Alliance).                             particular, the barriers to people accessing health
                                                      care and that currently, the majority of work
The Homelessness Action Group (HAG) is one of         focuses on housing. To better understand the
the action groups formed out of the Alliance and      barriers in the health sector for people without
convened by North Coast NSW Medicare Local            secure housing and the challenges experienced by
(NCNSWML).
                                                      health and community service workers planning
                                                      and delivering care, the Survey on Health Services
This report, developed by the HAG, provides an
                                                      for People without Secure Housing Northern NSW
overview of the results of the on-line Survey of
                                                      was developed.
Health Services for People without Secure Housing,
Northern NSW, over the period 11 April to 6 May       The survey was collaboratively designed and
2014. This work has been led by NCNSWML and           widely distributed with the support of both the
members of the Alliance’s Homelessness Action         health and homelessness support services sectors.
Group.                                                It was developed to better understand the barriers
                                                      in the health sector for people without secure
The survey has been well supported by both health     housing and the challenges experienced by health
services and the homelessness and support             workers planning and delivering care and targeted
                                                      those supporting the health and housing of these
services agencies.
                                                      people, as valuable informants about the problems
                                                      encountered by their clients, patients and services.

                                                      The scope of the survey included hospital inpatient
BACKGROUND                                            and emergency services, community based
                                                      services and primary health care services including
The Alliance was established under a                  general practice as well as a wide range of
memorandum of understanding (MOU) between             agencies providing housing and other support to
Northern NSW Local Health District (NNSWLHD),         people without secure housing.
the Department of Family and Community Services
(FACS) and North Coast NSW Medicare Local
(NCNSWML) in October 2013. This MOU
articulates a vision of

      “fostering a response to the needs
      of the vulnerable members of the
      North Coast community that is
      client centred, multi-sectoral and
      is integrated and cohesive where
      services are provided”. (See
      Appendix 1)

Central to achieving this vision has been the
establishment of relevant action groups to
respond to these needs. (See Appendix 2) The
Homelessness Action Group was formed in
response to the need for action to support the
health needs of people at risk of, or experiencing,
homelessness. The Terms of Reference for this
group was developed by the current membership
consisting of a variety of regional organisations

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SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW - A survey conducted by the Homelessness Action Group under the ...
SURVEY DESIGN AND                                           •   whether patients of health care services
                                                                are asked about their living situation
HOW IT WAS                                                  •   what problems are encountered by health
CONDUCTED                                                       service providers delivering services to
                                                                people without secure housing
The survey was administered via the on-line survey          •   quality of communication between health
tool, Survey Monkey. It comprised 26 questions                  services and support services
including 12 open ended questions directed at               •   suggestions from health care providers on
informants from organisations that primarily                    how to deliver more effective health care
provide health care services and those providing                to people without secure housing
support services for people without secure
housing. (See Appendix 4)                               Open ended questions were analysed manually by
                                                        coding sentences or part sentences and organising
Questions 2 to 11 were directed at organisations        into themes. Closed questions are presented
that primarily provide health care services.            directly from survey monkey.

Questions 13 to 25 were directed at organisations       It should be noted that for some questions
that provide support services for people without
secure housing.                                         (Q2 & 3) respondents were able to select more
                                                        than one response. This was unintended. For
Question 12 asked respondents if they would be          these questions, the denominator is the number of
prepared to participate in further discussions, and     respondents, rather than the number of
those that agreed were asked for their contact          responses. This anomaly will be corrected in
details in Question 26.                                 future surveys. Overall, these questions still
                                                        provide a good indication of the spread of agencies
The survey was distributed widely by email on 11
                                                        responding to the survey.
April 2014 via the Homelessness Action Group
(HAG) network to the Northern NSW Local Health
District, the NSW Department of Family and
Community Services, members of the Northern
Rivers Housing and Homelessness Forum,
Aboriginal Medical Services, General Practitioners
and NCML networks and the not-for-profit sector.
A three week time frame for the survey response
was provided initially, but responses received up
to the date of analysis on 6 May 2014 were
accepted. A follow up reminder email was sent on
29 April 2014.

The main issues covered by the survey include:

    •    ease or difficulty accessing health services
         by both clients and organisations
         providing support to them
    •    the factors that make a health service
         easy or difficult to work with
    •    the information required by a support
         organisation from a health service
    •    suggestions from support organisations
         on how to better support people without
         secure housing to access health services

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SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW - A survey conducted by the Homelessness Action Group under the ...
FINDINGS FROM THE SURVEY

SAMPLE OF RESPONDENTS

 Q 1. Is your organisation primarily a health care service?

Responses to the survey were well supported by both the health services and homelessness support services
sectors. A slightly greater response was received from the health care sector (158 responses or 54.7%) than
the homelessness and community services sector (131 responses or 45.3%) (Table 1).

Table 1
 Is your organisation primarily a health care service?

 Answer Options                                          Response Percent            Response Count

 Yes (skip to question 12)                               54.7%                       158
 No                                                      45.3%                       131
                                                                 answered question   289
                                                                  skipped question   1

RESPONSES FROM THE HOMELESSNESS AND COMMUNITY SERVICES SECTOR

Those organisations which were NOT primarily providing health care

(Questions 2 to 11 targeted organisations not primarily providing health care)

 Q 2. What is the primary focus of your organisation? (Choose the one that best fits)

The majority of respondents to the survey who are not primarily health care service providers were from:
homelessness, housing and accommodation services; multi focus agencies; family support services; domestic
and family violence and women’s services; and community development/information provision services. Full
details are shown in Table 2.

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SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW - A survey conducted by the Homelessness Action Group under the ...
Table 2*
 Primary focus of organisation (homelessness and community service provider)

 Answer Options                                                          Response Percent       Response Count

 Multi focus agency                                                            28.9%                   33
 Domestic and Family Violence and Women's Services                              7.0%                    8
 Mainstream eg Centrelink, Legal Aid, Financial Counselling                     3.5%                    4
 Homelessness Housing and Accommodation                                        37.7%                   43
 Education and Training                                                         6.1%                    7
 Family Support                                                                12.3%                   14
 Children's Services                                                            4.4%                    5
 Community Development /Information Provision                                   7.0%                    8
 Youth                                                                          7.0%                    8
 Other                                                                         18.4%                   21
*In Q2 & Q3 some respondents selected more than one response. The denominator is the total number of respondents.

 Q 3. Please select the statement that best describes your main role?

The majority of homelessness and community services respondents were either front-line service providers
(53.4%), or Managers (29.7%) (Table 3).

Table 3
 Main role of respondent (homelessness and community service provider)
 Answer Options                                                  Response                Response Count
                                                                  Percent
 Frontline Service Provider (main role is direct client            53.4%                        63
 contact and service provision)
 Manager                                                           29.7%                        35
 Administrative Support                                             5.9%                         7
 Other                                                             14.4%                        17

 Q 4. This survey is interested in those clients without secure housing. This may include people
 who are living rough, in transient or temporary accommodation or are having difficulty
 sustaining their tenancy. In relation to your clients without secure housing, how often do you
 encounter people reporting difficulty accessing health care?

The rate of reported difficulty in accessing health care services by people without secure housing is
shown in Table 4 below. 16.3% of organisations (who are not primarily health care providers)
encounter people without secure housing, reporting difficulty accessing health care every day, and
45% report this occurring every week (Table 4).

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SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW - A survey conducted by the Homelessness Action Group under the ...
Table 4
 How often do homelessness and community services service providers encounter people without secure
 housing reporting difficulty accessing health care

 Answer Options                                                        Response Percent        Response Count

 Every day                                                                   16.3%                    13
 Every week                                                                  45.0%                    36
 Every month                                                                 22.5%                    18
 Rarely                                                                      16.3%                    13
                                                                        answered question             80
                                                                          skipped question            210

 Q 5. What difficulties have they reported regarding access and use of health services?

Sixty four people responded to this open question about the difficulties reported by clients in accessing health
care services.

Key themes were cost, waiting times, transport costs and availability, lack of suitable services, understanding
the health system, homeless people having different priorities, judgment by others, no address for
correspondence, disability access, difficult to provide services when client has no home and security issues.

Some sample responses for the most frequently mentioned themes are provided below. A more detailed list of
sample responses is provided at Appendix 5.

Cost - mentioned 25 times:

 “particularly mental health but bulk billing doctors or any type of allied health is very difficult to access;
 lack of bulk billing especially in rural areas; lack of funds to pay for any pre-treatment options such as x-
 rays”

Waiting times- mentioned 20 times:

 “Wait lists for services; high waiting times to access the services presently available; availability of some
 specialists; wait lists for mental health; having to wait 3 weeks for an appointment; unable to access
 appropriate care in a timely manner”

Transport costs/availability – mentioned 19 times

 geographical isolation, inability to use public transport due to mobility or Mental Health issues; unable to
 get to services; unable to get to appointment with doctors; lack of transport to broaden options;

Lack of services - mentioned 12 times

 “Lack of Drop in Services; lack of services in the Tweed; no General Practitioner (GP); access to mental
 health support workers; access to primary health services; mental health and bulk billing; access to
 specialist services eg podiatrist, psychologist; health services OK but accessing housing is difficult”

Understanding the health system, age care, cultural barriers – mentioned nine times

 “Understanding the aged care system or other health system; not understanding what they need to do to
 secure services; knowledge of what exists; lack of knowledge of how to access mental health supports;
 lack of cultural awareness by local GPs”

                                                                                                                  10
Different priorities for homeless people – mentioned five times

 “Their housing is their main focus and priority – cannot look at health care needs until they secure
 housing; inability to remember appointments or work to a calendar/watch”

Judgement by others, fear, shame – mentioned five times

 “Judgement by providers; stigma, disempowered by ‘client/health provider’ relationship”

 Q 6. Based on your experiences, rate the level of ease or difficulty in dealing with the following
 services when coordinating care or case managing clients without secure housing.

Services most frequently mentioned as either good or easy to work with are
    • Aboriginal Health Services (66.3%),
    • Community Health Services (73.8%),
    • Drug and Alcohol services (58.8%)
    • General Practice (57.6%).

Services most frequently mentioned as difficult or very difficult to work with are
    • Mental Health Services (45%)
    • Hospital Inpatient Services (34.2%).

Opinions over ease of working with Mental Health Services are quite divided; they recorded the highest
number of ‘difficult to work with’ responses but also the equal highest number of ‘very easy to work with’
responses (Table 5; Figure 1).

 Table 5
 Ease or difficulty dealing with health care services for homelessness and community service
 providers
 Answer Options            Very easy       Good to      Difficult to      Very         I don't     Response
                            to work       work with     work with      difficult to     know        Count
                              with                                     work with

 General Practice             6.3%          51.3%          23.8%          5.0%         15.0%             80
 Hospital Emergency           3.8%          49.4%          20.3%          7.6%         20.3%             79
 Services
 Hospital Inpatient           1.3%          44.3%          24.1%         10.1%         20.3%             79
 Services
 Dental Services              2.5%          29.1%          21.5%          7.6%         39.2%             79
 Aboriginal Health            6.3%          60.0%          17.5%          3.8%         12.5%             80
 Services
 Community Health            12.5%          61.3%          12.5%          3.8%         10.0%             80
 Services
 Mental Health               12.5%          41.3%          25.0%         20.0%          2.5%             80
 Services
 Drug and Alcohol             7.5%          51.3%          22.5%          6.3%         13.8%             80
 Services
                                                                              answered question    81
                                                                                skipped question   209

                                                                                                              11
Figure 1

 Q 7.Please explain what makes a service easy to work with?

Seventy seven responses were received to this open ended question. Sixty four people responded to this open
question about the difficulties reported by clients in accessing health care services.

Key themes were:

    •      quality of systems, service delivery, and client centered service
    •      attitude of staff, relationships and understanding homelessness issues
    •      accessibility – cost and availability
    •      clear and open communication and information
    •      collaborative work practices

Some sample responses for the most frequently mentioned themes are provided below. A more detailed list of
sample responses is provided at Appendix 5.

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Quality of systems, service delivery, and client centered service - mentioned by 37 respondents.

 “clear eligibility and referral processes, shared case management; good referral systems, professionalism,
 organized internal systems, flexibility; commitment to client centered approach, ability to take on
 feedback; not sending clients around many services in circles (wrong door); timely response or call backs,
 they are client focused and have good referral networks; cultural competency, flexible outreach models,
 diversity of treatment models, early intervention and prevention services; structure, willingness,
 determination; return calls emails etc within a reasonable time frame, workers don’t dump difficult
 clients with inappropriate referrals; clear pathways;”

People; attitude, relationships, understanding homelessness issues – mentioned by 29 respondents.

 “non-judgmental, patient and non-threatening; attitude, non-judgmental, compassion, no prejudice,
 respect, listening etc friendly interested staff; genuine interest in helping people; staff understanding
 homelessness issues; being aware and adjusting attitude towards vulnerable people; having one person
 to talk to about a particular client (not having to explain the story to numerous people)”

Accessible – cost and availability- mentioned by 24 respondents.

 “the service has to be readily accessible; available to talk, give advice (to staff and potential patients)s;
 willing to accept bulk billing patients with no fixed address; taking on new patients; accessible, short
 waiting list/time;”

Clear and open communication and information – mentioned by 22 respondents.

 “being able to share information readily; being transparent, open and honest; explains what service they
 can provide, returns calls; open and honest communication; staff who can explain what support/service is
 available to clients and direct them appropriately if they are unable to assist; returning phone calls,
 feedback letter or discharge summary; they are quick to respond to calls/messages and take time to
 explain what is happening barriers;”

Collaborative work practices – mentioned by 14 respondents.

 “One that works in cohesion with other allied services; relationships between service providers and
 “health services are strong, with collaborative coordination of care; responsive because there is an
 established working relationship via engagement in mutual programs and inter-agencies, shared
 knowledge”

 Q 8. Please explain what makes a service difficult to work with?

Seventy four responses were received to this open ended question. Generally the responses to this question
were the opposite of responses to question seven. Key themes were; quality/internal systems, access
(availability and cost), staff attitude, poor communication, lack of integration and team work, and unrealistic
expectations.

Some sample responses for the most frequently mentioned themes are provided below. A more detailed list of
sample responses is provided at Appendix 5.

Quality/internal systems – mentioned by 26 respondents

 “firm guidelines not allowing flexibility, ‘not my job/role’ attitude; not being able to refer appropriately
 and too lazy to help client through the maze of processes; not able to brain storm/work around issues
 that arise – ie no flexibility not able to individualise; inefficient or non-existent referral system, non-
 professionalism, no organisation, non flexible in service delivery; not client focused and not willing to go
 beyond providing a basic service to clients; no outreach models, only service provision in regional centres,

                                                                                                                 13
lack of flexibility, stringent eligibility requirements, dilution of funding for supportive care models such as
 community mental health;”

Access – availability and cost - mentioned by 25 respondents

 “no vacancies/availability; accessibility and cost; do not accept bulk billing patients- have limited
 available appointments (long wait times); hard to access service, complex to refer, work in isolation, not
 working from trauma informed framework; unexplained hours of closing/meeting times; not enough case
 managers, case managers/support workers not attending services with clients”

Staff - attitude, non understanding - mentioned by 18 respondents

 “attitude, judgmental, prejudice (colour and poverty), arrogance, stereo-typing; impatient/rude
 /judgmental staff, threatening demeanor with nervous clients; staff who are rude, uninterested and
 unhelpful; no understanding of homelessness and how that impacts on clients lives professional snobbery,
 stigmatizing of clients with Alcohol and Other Drug (AOD) issues in particular; attitude that health service
 knows best; services that don’t understand the Aboriginal people;”

Poor communication – mentioned by 12 respondents

 “Not willing to provide information though confidentiality forms have been signed by client; poor
 communication to client; lack of ability to share information, health legislation makes this difficult
 where women and children are victims of domestic violence”

 Q 9. When your clients without secure housing are attending a health service, what information
 is MOST important for you to receive from the health service so you can support them with
 their housing problems?

Seventy three people answered this open ended question providing a comprehensive list of information
needs. Some examples of responses are listed below. A more detailed list of sample responses is provided at
Appendix 5.

    •   Thorough case management communications, Doctors’ reports, for effective outreach follow up and
        evaluation of recovery;
    •   Information about the support they will need to enable them to access secure housing;
    •   Ability to live in housing, specific health needs that will impact on seeking or living in housing;
    •   Mental health status; complex health needs and what supports are already involved;
    •   How to access service, public transport links and nearby accommodation options;
    •   What type of accommodation most/more suitable and why. The effects lack of secure housing has on
        clients wellbeing;
    •   Does the client have a condition that requires monitoring, and if so what has been put in place to
        ensure this is addressed, in particular with mental health conditions; reason for housing crisis, eg
        Black listed, mental health;
    •   Whether pet is medical companion;
    •   Documentation of injuries and impacts of domestic violence
    •   Person to contact from the health provider; recent A1 assessment, Comprehensive Risk Assessment
        and Management Plan, Substance Abuse Assessment if applicable), Care Plan and Workplace Health
        and Safety Community Mental health checklist
    •   Detailed support letter stating clients health condition and a realistic request for a particular product

                                                                                                               14
Q 10. In your experience, how often is this information currently provided to you?

Only 1.2% of homelessness and community services providers stated that they always received the
required information from health care services and 29.8% stated that it was rarely or never
provided. (See Table 6 and Figure 2.)

Table 6
 How often is the information required from health care services currently provided to homelessness and
 community service providers
 Answer Options                                             Response              Response Count
                                                             Percent
 Always                                                       1.2%                      1
 Most of the time                                            17.9%                     15
 Sometimes                                                   51.2%                     43
 Rarely                                                      25.0%                     21
 Never                                                        4.8%                      4
                                                     answered question    84
                                                       skipped question   208

Figure 2

                                                                                                          15
Q 11.Please suggest ways to better support people without secure housing to access the health
 care they need?

Sixty six responses were received to this open ended question. Key themes were:

    •   More funding, staffing, services
    •   Better access, bulk billing
    •   Information
    •   Transport
    •   Quality of service
    •   Training staff
    •   Increased collaboration and coordination

Some sample responses for the most frequently mentioned themes are provided below. A more detailed list of
sample responses is provided at Appendix 5.

More funding, staffing, services - mentioned by 22 respondents

 “dedicated services rather than multiple people trying to help; more health services equipped to handle
 mentally ill patients and patients who can’t handle schedules appointment-style services; Lack of staffing
 is a major concern in terms of access to health services, in this instance mental health services
 particularly; increased drop in services (outside of Lismore), facilitate health open days once per quarter
 with access for transient/rough sleepers to health services”

Better access, bulk billing - mentioned by 16 respondents

 “ensure services are accessible; more bulk billing; provide or promote more bulk billing in regional areas;
 easier access to dental, mental health and Aboriginal specific services; support workers to assist clients to
 fill in forms”

Information - mentioned by 16 respondents

 “Provide written information, especially contact details and names of staff referred; easy access to a local
 directory describing relevant health services, affordable options on an individual basis; organization
 constantly need to be advised about services available to clients; have more community knowledge about
 what is going on in Aboriginal communities; list of local GPs and other health providers willing to see new
 clients/bulk billing options;”

Transport - mentioned by 10 respondents

 More transport; transport funded to and from the health centre; we live in an area where public transport
 is non existent and the specialist services are often over 100 kms away, free transport is a good start;
 community transport more often and more flexible

 Q 12.Would you be prepared to participate further in discussions, consultations or the design of
 initiatives to improve health care for people without secure housing?

Thirty six (36) respondents out of a possible 131 responded positively to this question.

                                                                                                             16
RESPONSES FROM THOSE IDENTIFYING AS PRIMARILY HEALTH CARE SERVICE

(Questions 13 to 25 targeted organisations primarily providing health care)

 Q. 13. What is the primary focus of the health care service where you work?

Highest numbers of respondents to the survey from the Health Care sector were from Community Health
Services (29.1%), Mental Health Services (19.1%), Hospital Inpatient Services (17.3%), Hospital Emergency
Services (13.6%) and General Practice (9.1%) (see Table 7 and Figure 3).

Table 7
 Primary Focus of the Health Care Services

 Answer Options                            Response Percent               Response Count

 General Practice                          9.1%                           10
 Hospital Emergency Services               13.6%                          15
 Hospital Inpatient Services               17.3%                          19
 Dental Service                            1.8%                           2
 Aboriginal Health Services                4.5%                           5
 Community Health Services                 29.1%                          32
 Mental Health Services                    19.1%                          21
 Drug and Alcohol Services                 5.5%                           6
                     answered question     110                            110
                       skipped question    182                            182

                                                                                                            17
Figure 3

 Q. 14. What description best describes your role in the organisation?

The majority of health care service respondents were clinicians (71.3%) followed by managers (12.0%) (Table
8).

Table 8

 Role of respondent – health care services

 Answer Options                                              Response               Response Count
                                                              Percent
 Clinician                                                     71.3%                      77
 Manager                                                       12.0%                      13
 Administration Support                                         2.8%                       3
 Other                                                         13.9%                      15
                                                       answered question    108
                                                         skipped question   184

                                                                                                          18
Q 15. This survey is interested in those patients without secure housing. This may include
 people who are already homeless (living rough, in transient or temporary accommodation) or
 are having difficulty in sustaining their tenancy and so are at risk of becoming homeless. In
 your experience, how often does your service provide health care for patients without secure
 housing?

More than a third of health care service providers (36.4%) care for a person without insecure housing at least
once a day and a further third (33.6%) at least once per week (Table 9 and Figure 4).

Table 9
 Frequency of care of patients without secure housing – health service providers

 Answer Options                                                Response               Response Count
                                                                Percent
 A number of times every day every week                          17.3%                       19
 At least one person - someone most days                         19.1%                       21
 Someone every week                                              33.6%                       37
 Someone every month                                             14.5%                       16
 Rarely                                                          11.8%                       13
 I don't know                                                    3.6%                        4
                                                        answered question     110
                                                          skipped question    182

Figure 4

                                                                                                             19
Q 16. Reflect on a time you were caring for someone that did not initially identify they had
 housing difficulties, but this was later disclosed during this period of care. Are patients asked
 about their living situation when they visit your health service?

Less than half (48.1%) of health care respondents always ask clients for details about their housing situations
(Table 10).

Table 10
 Are patients asked about their living situation when they visit a health care service

 Answer Options                                                              Response         Response Count
                                                                              Percent
 Always                                                                        48.1%                 52
 Most of the time                                                              24.1%                 26
 Sometimes                                                                     18.5%                 20
 Rarely                                                                        2.8%                  3
 Never                                                                         2.8%                  3
 Don't know                                                                    3.7%                  4
                                                                      answered question     108
                                                                        skipped question    184

 This means that health care providers have no knowledge of the housing situation of over 50% of clients.

 Q 17. Please describe any other mechanism your service has in place to alert you if a patient
 does not have secure housing.

Forty seven people responded to this question with a wide range of comments including that assessments are
made by other people (e.g. triage), they come as referrals, they are asked for a mailing address each time they
ask for an appointment, Doctor asks about living arrangement, or an address is always needed.

 Q 18. Describe problems you encounter in delivering or planning care when patients without
 secure housing are not adequately identified early?

Seventy two responses were received to this question. This question supposedly limits the respondent to
situations where insecure housing was not identified early. Some replied to that question, for example ‘in my
experience this has not happened’, but the majority of respondents answered more generally about problems
delivering or planning care for homeless clients which are addressed more fully in following questions
Therefore only those few responses which appear to answer the question correctly have been provided below

 •    Some are at risk of homelessness when we first contact for case management and then find themselves
      homeless
 •    In my experience this has not happened
 •    they are identified early
 •    Identification is not the main problem, the problem occurs when you are unable to do anything about
      the situation
 •    Early identification or late identification - the problem is one of housing supply
 •    Causes significant problems when planning their treatment options
 •    Hasn't been an issue to date

                                                                                                               20
Q 19. When caring for patients identified as being without secure housing, what information
 would be helpful to your service to better address their health care needs?

Sixty five responses were received to this open ended question. Key themes were:

    •   How to access emergency and secure housing, or a drop-in centre
    •   Support services and pathways
    •   Information about the client
    •   Access to social workers or care workers

Some sample responses for the most frequently mentioned themes are provided below. A more detailed list of
sample responses is provided at Appendix 1.

How to access emergency and secure housing, or a drop-in centre - mentioned by 30 respondents

  “Somewhere they can go even temporarily whilst recovering; where there is a drop in situation for
 showering and clothes washing, meals; temporary accommodation they can access in Casino; crisis
 accommodation access; after hours accommodation list; location and availability of supported care living
 options; a central housing information hub would be useful;”

Support services and pathways – mentioned by 13 respondents

 “Simple information on pathway to access secure housing and case management support to do so; what
 services are available to provide housing support and pathways for referral; knowing what is available
 for these persons to access upon discharge from hospital while they are recovering eg accommodation,
 services that will accept such clients or case management services”

Information about the client – mentioned by seven respondents

 “previous health, psychosocial history, current family and social support in place; where they have been
 living or with who, previous difficulties with housing, any financial difficulties (not details, just general
 issues); other supports, community programs involved and their input, prognosis and expected medical
 outcomes or friends national pharmacy/medical information scheme”

Access to social workers or care workers – mentioned by four respondents

 “The contact details of a liaison officer or care workers to ensure results are followed up; access to social
 housing workers; social workers to contact”

 Q 20. How would you describe the overall communication you have with other agencies
 involved in supporting a person identified as being without secure housing?

Only a small proportion of respondents stated that communication was excellent (6.4%). The most frequent
response to this question is “communication is sometimes good but it relies on my individual relationships’
(29.8%) followed by ‘communication is mostly good’ (23.4%). Almost one quarter of respondents stated that
communication is either poor (12.8%) or very bad (9.6%) (Table 11).

                                                                                                                 21
Table 11
 Level of communication with other agencies

 Answer Options                                             Response          Response Count
                                                            Percent
 Most services are excellent and I get the information I    6.4%              6
 need to help the patient
 Communication is mostly good                               23.4%             22
 Communication is sometimes good but it relies on my        29.8%             28
 individual relationships
 Communication is generally poor                            12.8%             12
 Communication is very bad and it makes it difficult for    9.6%              9
 me to meet the needs of the patient
 Not applicable in my role                                  18.1%             17
                                                       answered question      94
                                                           skipped question   198

Figure 5

                                                                                               22
Q 21. Please explain why you chose this response?

The 73 responses to this question were varied and there were no particular themes or trends identified.

Respondents stating that communication was ‘very bad’ or ‘poor’ had various experiences including: non-
availability of social workers, non-availability of services such as accommodation, services not available after
hours, services refusing care if there is no address, or not being aware of what was available. Lack of a
standard practice, overwhelming bureaucracy, or simply ‘no communication lines’ were also provided as
explanations for their response to Question 20.

 Q 22. When caring for people who do not have secure housing, is it clear to you who to contact
 for assistance with:

In many cases health care service workers are not clear about who to contact for assistance with patients
without secure accommodation. Greatest clarity exists around the services available to support health and
well being (40.2% are clear). Least clarity is around issues relating to case management being undertaken by
other agencies (42.4% unclear) (see Table 12).

Table 12
 Is it clear who to contact for assistance with:
 Answer Options                                     Yes           No         Not Sure     N/A to my    Respons
                                                                                           type of     e Count
                                                                                          service or
                                                                                             role
 Issues about retaining their current              34.8%         31.5%         19.6%        14.1%          92
 accommodation
 Issues about finding new or more secure           38.0%         35.9%         14.1%        12.0%          92
 housing
 Issues relating to case management                25.0%         42.4%         19.6%        13.0%          92
 being undertaken by other agencies
 Planning transfer of care from hospital           25.3%         36.3%         15.4%        23.1%          91
 (discharge) for people without housing
 Planning to deliver care in a community           33.3%         29.0%         23.7%        14.0%          93
 setting including assistance with post
 discharge care
 Identifying what services are available to        40.2%         31.5%         21.7%         6.5%          92
 the patient that could support their
 health and wellbeing
                                                                                  answered question             94
                                                                                    skipped question         198

 Q. 23. Please describe the BIGGEST difficulty you experience when providing health care
 services to people without secure housing who visit your service?

Eighty nine responses were received to this open ended question. Key themes were:

    •      Making contact, following up, home visit
    •      Self care, personal wellbeing and self esteem issues for the individual and children
    •      Lack of appropriate housing/ emergency/crisis housing
    •      Health care not a priority for homeless people
    •      Discharge planning
    •      Lack of services

                                                                                                                   23
Some sample responses for the most frequently mentioned themes are provided below. A more detailed list of
sample responses is provided at Appendix 5.

Making contact, following up, home visit – mentioned by 20 respondents

 “Making contact, making appointments, finding a venue to offer treatment; inability to follow up or visit
 at home; stability, consistency in offering ongoing care; to ensure the baby will be cared for in a safe
 environment and they are close to medical services; we cannot plan long term care, for instance putting
 in necessary home modifications; Collecting I.D to get services to get housing”

Self care, personal wellbeing and self esteem issues for the individual (and children) – mentioned by 16
respondents

 “Self esteem, self care issues, difficult to care for people who have little regard for themselves; their
 immediate needs are critical and the needs of the parent and or child can be compromised in the near
 future or the long term; responding to levels of stress, poverty, exposure to violence”

Lack of appropriate housing/ emergency/crisis housing – mentioned by 15 respondents

 Our inability to find housing for them; they do not want assistance, just a bed for the night out of the
 elements; solve the accommodation and their crisis resolves; no available emergency housing options AT
 ALL!; finding secure housing and avoiding admission to hospital; lack of emergency housing and the ten
 year waiting list for housing commission house”

Health care not a priority for homeless people – mentioned by 12 respondents

 “difficult to focus on any health issue when not securely housed; their housing becomes their focus and all
 sorts of mental health issues are exacerbated such as anxiety and depression; unable to address other
 issues (D&A, child protection etc) without secure housing;”

Discharge planning – mentioned by six respondents

 “Patients want to remain in hospital because they have no accommodation available; prolonged stay in
 mental health inpatient unit with subsequent bed block resulting in other patients awaiting a bed in step
 down unit. Often waiting for weeks in High Dependency Unit when this care is no longer required”

Lack of services – mentioned by three respondents

 “No social worker; mental health clients needing supported accommodation; providing support services
 for young people trying to support them to get secure accommodation is the biggest challenge, especially
 when they need support”

                                                                                                             24
Q 24. What OTHER difficulties do you encounter when providing health care services to people
 without secure housing who visit your service?

Seventy nine people responded to this question. These comments are varied with themes difficult to identify.
Only themes/comments not covered in Question 23 are listed below. A more detailed list of sample responses
is provided at Appendix 5.

    •   Food insecurity, financial difficulties, mental health issues, women facing homelessness. I had a client
        who was on a program that was supposed to assist her retain her accommodation due to hoarding,
        when I spoke to the person involved she stated "she is no longer on the 16 week program" as when
        she spoke to client several times on the phone she stated everything was ok, after the program was
        finished the client was evicted due to her issues and was homeless. I wanted to know why the
        program hadn’t been out to the clients home.
    •   We see a lot of people who are angry and frustrated at the system. who have been sent from one
        service to another and land back here as they don’t know where else to go. It is then our job not only
        to find services to provide them with their needs but also to calm them into believing we are trying to
        assist them with their needs.
    •   Undertaking the physical requirements of looking for secure housing when one is on chemotherapy or
        radiation therapy is near impossible for many.
    •   Insecurity from patients and confusion
    •   They repeatedly seek the service even if other advocates have attempted to align them with
        alternatives to health care through a GP, or community service.
    •   Being unsure who else may be present in temporary accommodation can pose security issues
    •   On-going care for patient - referral to COPS is excellent, concerned they become non-government org.
    •   Difficulties with referral to Hospital in the Home Program.
    •   Often multifactorial and can include mental health issues for themselves and involved people - can be
        hard to develop rapport and trust/ compliance issues - not a word I like but can be a huge issue.
    •   Only feeling helpless to provide any assistance when they disclose their living situation with me.
    •   Intergenerational lack of basic skills or cooking, cleaning, washing, budgeting. They often have a long
        history of problematic rental & sharing housing, with eventual homelessness due to inability to cope
        with the multiple factors in caring for a home. Linking to health services is almost impossible, unless
        there is a point of contact eg The Winsome in Lismore.
    •   Ensuring safe secure places for children of these people

 Q 25. Please suggest what would help you to deliver more effective health care to people
 without secure housing.

Eighty three responses were received to this open ended question. Key themes were:

    •   More housing available
    •   A centrally located service
    •   Information about housing and services
    •   Services, social workers, case management support

Some sample responses for the most frequently mentioned themes are provided below. A more detailed list of
sample responses is provided at Appendix 1.

More housing available – mentioned by 34 respondents

 “a short term housing situation where post patients can recover and receive services; increase in stock of
 affordable housing, more social housing and/or crisis accommodation; more crisis accommodation for

                                                                                                              25
men not located at a pub; by giving them a place to stay overnight as opposed to long term housing;
 more housing options in rural areas; more low cost accommodation is urgently needed in the Tweed area-
 small I bed units especially; respite – convalescence places for post medical issues that don’t require ACAT
 or have ‘nursing home’ stigma”

A centrally located service – mentioned by 14 respondents

 “A centrally located service. an outreach worker to see clients at this clinic as a one stop facility; a contact
 hub for phone messages, mail and venue for appointments; Venue for drop in service; community clinics
 co-located with welfare services; centrally located service where clients can receive outpatient care/clinic;
 a local resource centre; to have a clinic where they go to receive all services who can give long term care
 ;a hub that the homeless felt comfortable to go to as a central/safe contact point; central point of contact
 where clients can receive outpatient care/ clinic.”

Information about housing and services –mentioned by 12 respondents

 “Printed (web) resource detailing steps a person can take, local resources (and what they actually do);
 having a clear pathway for clients to follow to find secure housing; someone to contact for follow up;
 telephone advice line; available options for young people aged between 12-25 yrs;”

Services, social workers, case management support – mentioned by 12 respondents

 “Case management support to people who need to access secure housing; more assisted accommodation
 packages; SOCIAL WORKERS!; more community welfare support officers; welfare officers or social
 workers; supervised, supported accommodation specifically designed for people who have failed to
 maintain a home”

                                                                                                                26
DISCUSSION
The purpose of this survey was to better understand the barriers in the health care sector for people without
secure housing and the challenges experienced by health workers planning and delivering care.

The responses to the survey were wide ranging with people from both health and non-health related
organisations participating in fairly even proportions.

The 12 open ended questions provided opportunity for respondents to expand on responses and provide
detailed information about barriers, challenges and solutions. They made clear the complexities involved in
providing more effective health care, with many responses being multi-faceted.

For people without secure housing barriers to access include cost, waiting times, transport, lack of services,
and lack of understanding about the health system and fear of judgement.

 Agencies providing support to people without secure housing (not primarily health care) found some health
care services easier to work with than others, citing quality of service delivery, staff attitudes and
understanding of homelessness, accessibility, communication and collaborative work practices as key to
working with a service easily.

These agencies stated that only a small proportion of health care services always provided the information
they required and provided a detailed list of the information they require to assist clients with their housing
problems. When asked about ways to better support people without secure housing to access health care,
more funding/staffing/services, better access including more bulk billing, more low cost transport, and better
information provision were the key themes emerging.

Generally these agencies who primarily provide health care noted communication difficulties with other
agencies involved in supporting a person without secure housing. They reported that better information about
the client, support services and pathways available, how to access emergency housing, and access to social
workers or care workers, would allow them to better address health care needs.

These agencies also reported a lack of clarity around who to contact for assistance when caring for people
without secure housing.

When asked to describe the biggest difficulty experienced in providing health care to people without secure
housing the key themes to emerge were: making contact, following up, home visits; self care, personal
wellbeing for the individual and children; lack of appropriate emergency housing; health care not being a
priority for people without secure housing; discharge planning and lack of services.
When asked for suggestions about what would help them to deliver more effective health care to people
without secure housing, key responses from respondents who primarily provide health care include increased
housing availability, a centrally located service; information on housing and services; social workers and case
management support.

The following points summarises the key findings

•    Barriers to accessing health care include cost, waiting times, transport, lack of services and lack of
     understanding about the health system and fear of judgement.
•    Inability to identify a home address made it difficult to secure appointments, particularly where these
     were notified by mail and also on the ability to provide outreach services.
•    Agencies found some health care services easier to work with than others, citing quality of service
     delivery, staff attitudes and understanding of homelessness, accessibility, communication and
     collaborative work practices as key to effective working relationships.
•    Generally, only a small proportion of health care services always provided agencies with sufficient and
     detailed information required to assist clients.

                                                                                                                 27
•   The survey highlighted a lack of clarity around ‘who to contact’. Communication difficulties between
    agencies was a commonly identified and identified the need for an improved mechanism to share
    information on
         o clients and their healthcare needs
         o availability of support services and pathways
         o access to emergency housing
         o social workers or care workers who could assist navigating the healthcare or social housing
              sector.
•   A consistent theme was the perception that health services were not sensitive to the trauma experienced
    by people without secure housing and didn’t understand the problems they encountered. It was reported
    that this impacted upon the clients perception of being judged or discriminated against, and also the
    ability of healthcare workers to deliver effective client centred health care.

                                                                                                        28
CONCLUSION
In conclusion, this survey has provided detailed information about barriers to accessing health care and
challenges in providing services for people without secure housing. It also provides suggestions for more
effective health care delivery and ways to support clients to better access health care.

The information needs of both health care and homelessness support agencies are now documented as a
result of the survey.

The information from this survey will provide a resource for health care and other agencies providing services
to people without secure housing to assist them with service planning, developing checklists for information
requirements, and advocacy.

The information from this survey provides a base line for further research and reporting on a number of
aspects of the provision of health services to people without secure housing. Future surveys can utilise the
information from the open ended questions in this survey to develop a survey with fewer open ended
questions that will be easier to analyse and report. Additionally, this report will form a basis for future
discussions and progression on actions.

                                                                                                               29
APPENDIX 1
 North Coast NSW Alliance to Improve Services to the Vulnerable Members of
              the Community Memorandum of Understanding

VISION & AIM

The North Coast NSW Alliance to Improve Services to the Vulnerable Members of the Community has the vision
of fostering a response to the needs of the vulnerable members of the North Coast community that is client
centred, multi-sectoral and is integrated and cohesive where services are provided.

The population groups the Alliance will focus its work are
•       The Homeless
•       People with Disability
•       Children and Young People at Risk of Significant Harm

OBJECTIVES OF THE PARTNERSHIP

The objectives of the Alliance are

• Determine and set the framework and agenda for addressing the needs of the vulnerable members of the
  North Coast North Coast of NSW community
• Work to foster and facilitate greater cross agency collaboration and partnership
• Facilitate and champion the agenda for addressing the complex needs of the homeless, people with
  disabilities and children and young people at risk of significant harm.

FRAMEWORK AND AGENDA

Two levels of work will be pursued
(1)     System change (driven by Alliance and the Leadership Group)
(2)     Service Integration (driven at the service delivery level)

Lasting outcomes are achieved when integration and changes takes place at both above mentioned levels.

Pivotal to a fruitful collaboration and partnership is an overarching framework that gives shape to activities
and initiatives. This framework will facilitate

• Development of common priorities
• Delineation of responsibilities for involved agencies
• Achievement of higher degrees of coherence and integration within, and among, the various organisations
  and agencies.

The Leadership Group sets the framework, the priorities and the overall direction for the Alliance. It receives
reports and tracks the implementation of the actions.

The Leadership Group will ensure systematic, persistent and cohesive action to achieve the objectives of the
Alliance, including

• Undertaking joint strategic and operational activities (including needs assessment, use of common tools
  and definitions, joint planning and evaluation)
• Setting and aligning Performance Indicators that measure outcomes and whole-of-system improvement
• Sharing (where appropriate) de-identified and aggregated data, and information
• Determining mechanisms for sharing resources (where possible) in order to achieve the best outcomes and
  best value for the community and clients

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