44 Focus
Nurses are well positioned to positively affect the health and care of homeless people, writes Jessica Kenny
Caring for the homeless Homelessness marginalises people in many ways, but its negative effects are particularly acute in the context of access to healthcare. In Ireland the median age of death of a homeless man is 43 years and lower for a woman at 41 years. 1 This is almost half the life expectancy of the gen- eral population. Dublin in particular is seeing increasing numbers of homeless patients in adult and children’s hospitals. The inclusion of com- munity and primary care services in the care plans of homeless patients being dis- charged is essential. to medication on discharge and not communicating discharge information/ appointments to the relevant people. This has improved with the introduction of the inclusion health posts in the hospitals. The hospital staff and community services also now meet regularly to look at complex cases and how best to manage the health needs of this cohort and try to plan for safe discharges.
The area of ‘inclusion health’ has made significant advances in the past few years with the introduction of new hospital posts that have proven to be very effective. In Dublin, the Mater Misericordiae Univer- sity Hospital and St James’s Hospital are piloting projects aimed at improving the health of those traditionally on the mar- gins of healthcare. This was in response to an identified need for a co-ordinated approach in caring for homeless people. It is based on the HSE National Office for Social Inclusion’s aim of reducing inequal- ities in health. A lot of this is done through increased co-ordination of care and services between the community and the hospitals. People who are homeless often have negative experiences with authority and healthcare services. The reasons for this are complex but must be recognised and acknowledged. The introduction of inclusion health nurse posts has allowed a single point of contact for the community services which is invaluable. Where possible, staff (clinical and non-clinical) working with homeless people in the community are encouraged to participate and are included in care plans. It is community services and home- less agencies that we rely on to implement patient care plans on discharge. Direct access to a specialised nurse in the hospi- tal who is also familiar with the real health and social issues that people are facing on discharge has been shown to be very effective. Safe discharges are promoted and pri- oritised throughout the Irish healthcare system. However, this is an area in which, at times, we are failing for the homeless. This can come down to lack of access
Homeless people have significantly higher morbidity and mortality rates than those of the general population. Stud- ies have shown that homeless people account for a disproportionate number of attendances in emergency departments and are at a higher risk of re-attendance due to social, health, housing and addic- tion issues. 2 Additionally, the presence of a mental illness, alcohol and drug addiction leads to a significantly higher attendance rate than those without these factors. Homeless people do not usually have a registered address and are documented as ‘NFA’ (no fixed abode). This leads to significant administrative difficulties communicating through the normal hos- pital procedure, such as posting outpatient appointments. It is not surprising, there- fore, that there is a high ‘did not attend’ rate among this cohort. As healthcare workers, we need to be more imaginative when caring for homeless people who are on the margins of our healthcare system. National reports stress the ‘inappropriate usage’ of EDs by homeless people for refuge and shelter and urge that this situation be addressed. However, this also presents healthcare workers with a unique opportunity to engage. Homeless people are often discharged into inappropriate accommodation with poor aftercare or respite services available to them. This can result in repeat attendances, usually with similar complaints. This is neither cost-effective nor efficient and it is detrimental to their health and wellbeing.
Providing nursing services to homeless and marginalised people, while extremely challenging, is also very rewarding. When trust is gained, co-operation often follows, and it is extraordinary how rapid progress can be made. Having a holistic multi- disciplinary and multisectoral approach is valuable and allows maximum assis- tance to be given. Such considerations are essential when designing a care plan since healthcare is often not the priority for homeless people, given the chaotic nature of their lives. Continued and persistent engage- ment allows a nurse to really know the patients and their needs and a high level of trust can be developed. Since nurs- ing traditionally plays a large part in the co-ordination of care in the hospital and primary care setting this puts us in a critical position to positively affect the health and care of homeless people. Given the stark mortality and morbidity rates among those who are homeless, health- care workers have a vital role to play in breaking down the barriers that are pres- ent for this patient group. Jessica Kenny is an ANP candidate at the Mater University Hospital, Dublin References 1.Ivers JH,Zgaga L,O’Donoghue-Hynes B,Heary A, Gallway B,Barry J.Five-year standardised mortality ratios in a cohort of homeless people in Dublin.BMJ Open 2019 2.O’Reilly F,Barror S,Hannigan A,Scriver S,Ruane,L, MacFarlane A,O’Carroll A.Homelessness: An Unhealthy State.Health status,risk behaviours and service utilisation among homeless people in two Irish cities. Dublin:The Partnership for Health Equity (2015)
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