SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW

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

SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW

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 2

SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW

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 Members of the Community Memorandum of Understanding 30 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 3

SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW

EXECUTIVE SUMMARY The Survey on Health Services for People without Secure Housing, Northern NSW was conducted by the Homelessness Action Group (HAG) which was established by the North Coast NSW Alliance to Improve Services to the Vulnerable Members of the Community (The Alliance) in May 2014. The Alliance was established under a memorandum of understanding between Northern NSW Local Health District (NNSWLHD), the Department of Family and Community Services (FACS) and North Coast NSW Medicare Local (NCNSWML) in October 2013.

The Terms of Reference articulate 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) The Alliance established the Homelessness Action Group to “drive action and empower people experiencing or at risk of homelessness and those delivering services to facilitate change”(See Appendix 2). The Survey of Health Services for People without Secure Housing Northern NSW, was collaboratively designed and widely distributed with the support of both the health and homelessness support services sectors. It was developed to better understand the barriers in the health sector for people without secure housing and the challenges experienced by workers planning and delivering care and support.

The scope of the survey included hospital inpatient and emergency services, community based services and primary health care services including general practice as well as a wide range of agencies providing housing and other support to people without secure housing. The survey was administered via the on-line survey tool, Survey Monkey. It comprised 26 questions including 12 open ended questions directed at informants from organisations that primarily provide health care services and those providing support services for people without secure housing. Of the 289 responses, 54.7% were received from the health care sector and 45.3% from the homelessness and community services sector, representing a relatively even response from the two sectors.

Issues covered include accessibility to health services, information needed, problems encountered, communications and suggestions for improvements. The open ended questions provided opportunity for respondents to provide detailed information about barriers, challenges and solutions demonstrating the multi-faceted complexities in providing effective health care.

  • 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.
  • 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 4
SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW

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.

SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW

INTRODUCTION This report has been compiled under the leadership of the North Coast NSW Alliance to Improve Services to Vulnerable Members of the Community (the Alliance). The Homelessness Action Group (HAG) is one of the action groups formed out of the Alliance and convened by North Coast NSW Medicare Local (NCNSWML). This report, developed by the HAG, provides an overview of the results of the on-line Survey of Health Services for People without Secure Housing, Northern NSW, over the period 11 April to 6 May 2014. This work has been led by NCNSWML and members of the Alliance’s Homelessness Action Group.

The survey has been well supported by both health services and the homelessness and support services agencies. BACKGROUND The Alliance was established under a memorandum of understanding (MOU) between Northern NSW Local Health District (NNSWLHD), 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 from the health and homelessness and community services sectors. (See Appendix 3) The Homelessness Action Group quickly identified the limited data relating to homelessness and in particular, the barriers to people accessing health care and that currently, the majority of work focuses on housing.

To better understand the barriers in the health sector for people without secure housing and the challenges experienced by health and community service workers planning and delivering care, the Survey on Health Services for People without Secure Housing Northern NSW was developed.

The survey was collaboratively designed and widely distributed with the support of both the health and homelessness support services sectors. It was developed to better understand the barriers in the health sector for people without secure housing and the challenges experienced by health workers planning and delivering care and targeted those supporting the health and housing of these people, as valuable informants about the problems encountered by their clients, patients and services. The scope of the survey included hospital inpatient and emergency services, community based services and primary health care services including general practice as well as a wide range of agencies providing housing and other support to people without secure housing.

SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW

SURVEY DESIGN AND HOW IT WAS CONDUCTED The survey was administered via the on-line survey tool, Survey Monkey. It comprised 26 questions including 12 open ended questions directed at informants from organisations that primarily provide health care services and those providing support services for people without secure housing. (See Appendix 4) Questions 2 to 11 were directed at organisations that primarily provide health care services. Questions 13 to 25 were directed at organisations that provide support services for people without secure housing.

Question 12 asked respondents if they would be prepared to participate in further discussions, and those that agreed were asked for their contact details in Question 26.

The survey was distributed widely by email on 11 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
  • whether patients of health care services are asked about their living situation
  • what problems are encountered by health service providers delivering services to people without secure housing
  • quality of communication between health services and support services
  • suggestions from health care providers on how to deliver more effective health care to people without secure housing Open ended questions were analysed manually by coding sentences or part sentences and organising into themes. Closed questions are presented directly from survey monkey.

It should be noted that for some questions (Q2 & 3) respondents were able to select more than one response. This was unintended. For these questions, the denominator is the number of respondents, rather than the number of responses. This anomaly will be corrected in future surveys. Overall, these questions still provide a good indication of the spread of agencies responding to the survey. 7

SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW

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.

SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW

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 Percent Response Count Frontline Service Provider (main role is direct client contact and service provision) 53.4% 63 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). 9

SURVEY OF HEALTH SERVICES FOR PEOPLE WITHOUT SECURE HOUSING NORTHERN NSW

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 xrays” Waiting timesmentioned 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 to work with Good to work with Difficult to work with Very difficult to work with I don't know Response Count General Practice 6.3% 51.3% 23.8% 5.0% 15.0% 80 Hospital Emergency Services 3.8% 49.4% 20.3% 7.6% 20.3% 79 Hospital Inpatient Services 1.3% 44.3% 24.1% 10.1% 20.3% 79 Dental Services 2.5% 29.1% 21.5% 7.6% 39.2% 79 Aboriginal Health Services 6.3% 60.0% 17.5% 3.8% 12.5% 80 Community Health Services 12.5% 61.3% 12.5% 3.8% 10.0% 80 Mental Health Services 12.5% 41.3% 25.0% 20.0% 2.5% 80 Drug and Alcohol Services 7.5% 51.3% 22.5% 6.3% 13.8% 80 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.

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 availabilitymentioned 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, nonprofessionalism, 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 patientshave 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 Percent Response Count 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.

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 Percent Response Count 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 Percent Response Count 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 Percent Response Count 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).

Table 11 Level of communication with other agencies Answer Options Response Percent Response Count Most services are excellent and I get the information I need to help the patient 6.4% 6 Communication is mostly good 23.4% 22 Communication is sometimes good but it relies on my individual relationships 29.8% 28 Communication is generally poor 12.8% 12 Communication is very bad and it makes it difficult for me to meet the needs of the patient 9.6% 9 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: nonavailability 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 type of service or role Respons e Count Issues about retaining their current accommodation 34.8% 31.5% 19.6% 14.1% 92 Issues about finding new or more secure housing 38.0% 35.9% 14.1% 12.0% 92 Issues relating to case management being undertaken by other agencies 25.0% 42.4% 19.6% 13.0% 92 Planning transfer of care from hospital (discharge) for people without housing 25.3% 36.3% 15.4% 23.1% 91 Planning to deliver care in a community setting including assistance with post discharge care 33.3% 29.0% 23.7% 14.0% 93 Identifying what services are available to the patient that could support their health and wellbeing 40.2% 31.5% 21.7% 6.5% 92 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 areasmall 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.
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