Recuperating after a hospital stay can be tough for anyone, but for people without a home, finding a place to recover is even more challenging.
Cathy O’Leary reports
When Dr Andrew Davies was fine-tuning the manual for WA’s first medical respite for rough sleepers, he faced early resistance from some GPs about how it should be run.
Some doctors wanted to test residents for drugs and alcohol, but he wasn’t keen on a monitoring or punitive approach or excluding people because of drug use or mental health problems.
“One of the things I’ve often said is that homelessness is about people falling through the gaps,” says Dr Davies, who has years of experience as CEO and medical director of Homeless Healthcare, which he set up in 2008.
“That’s why they end up homeless in the first place. They don’t get treated by the mental health people because they’ve got a drug and alcohol problem, and the drug and alcohol people won’t treat them because they’ve got a mental health problem.”
Homeless Healthcare was the first service of its kind nationally, becoming the largest specialist homelessness primary care service in Australia, and since 2008 it has supported more than 5000 people experiencing homelessness through a range of clinics and out-reach services.
Its medical respite centre, which opened its doors last October, provides 20 short-stay medical beds to care for homeless people after a hospital presentation or admission in the Perth metropolitan area.
With the State Government providing $4.4 million over two years, the centre was designed to offer post-acute care in a safe environment, while also linking people to services to help break the cycle of homelessness.
The centre is operated by a consortium led by Homeless Healthcare with Ruah Community Services and Uniting WA, following a tender process.
It is based at a former backpacker hostel once known as the Witch’s Hat, in Northbridge.
Co-located are 10 non-medical ‘step down’ beds, which are funded philanthropically and called StayWitch’s in a nod to the past. These beds are designed for people who no longer require medical support but are not ready to leave.
24-hour care
Residents aged 18 and over can stay for a period of up to 14 days in either service, and admission to the medical respite is by referral. GPs run morning clinics on site every day, while the facility is staffed by nurses overnight and has peer support workers onsite during the day.
It is hoped that the facility could significantly reduce rates of hospital admission and readmission in vulnerable rough sleepers.
“As a GP who has been working in this area since 2014, it’s one thing having GP clinics, but it’s quite another thing seeing people discharged from hospital and then having to send them back because they’ve deteriorated,” Dr Davies said.
“Having the ability to bring someone into a recovery-focused environment has been a real game-changer for stabilising people and getting them out of homelessness.”
Dr Davies said the idea for the centre came from a Boston facility which had a very medical focus, with 112 curtained-off beds so it looked like a hospital – and the concept was tweaked from there.
“That facility doesn’t have a lot of input from case workers, yet they have shown very good reductions in this cycle in and out of hospital for people experiencing homelessness,” Dr Davies said.
“The thing I really wanted to add to it was the case management side of things, to get people socially stable because I think that’s the single biggest thing that’s impacting their health.”
Perth’s medical respite centre was endorsed by the State Government’s Sustainable Health Review, which highlighted the complexity of issues facing one of the most vulnerable groups in our society.
Homeless people face a high rate of chronic health issues, often have complex co-morbidities and can often have conditions left undiagnosed and untreated for long periods of time. This results in an over-reliance on acute health services.
The medical respite centre provides a safe space for people to recoup, sleep, eat nutritionally and escape the daily ‘fight or flight’ way of living on the street.
It also allows support workers to connect people to housing and accommodation and other community supports, and provides a window of opportunity to develop skills for independent living and help people transition out of homelessness.
Accessibility
Zoe Thebaud, who is director of residential services at the centre, said it was important not to exclude people by using rigid eligibility criteria. Drug and alcohol services, for example, are actively encouraged to refer people to the respite facility.
“Our primary cohort are people who are rough sleeping, and we recognise that there are multiple degrees of homelessness,” she said.
“There were a lot of people who were falling through the gaps in terms of being in hospital and needing mental health support, but their referral to a mental health step-down was being denied because they had alcohol and drug complications.
“Or services were trying to get them straight into rehab, but the mental health component meant they were falling through the gaps.”
Ms Thebaud said residents could take part in painting, cooking and other activities, and had access to computers and phones.
To reset their sleep cycles, they were encouraged not to stay in their rooms during the day and it was made clear that the facility was not a hotel so residents did their own washing, and while three meals were provided each day, they could use the kitchen to cook.
“It’s very empowering because people experiencing homelessness don’t have a lot of access to a kitchen to be able to cook something or eat healthily,” she said.
“We had a woman who loved ironing and would line up all the residents and offer to iron their clothes. We’ve had lots of wonderful characters come through, and they’ve made it what it is, and it’s been a real learning experience for us.”
Residents are discharged from the medical beds when their health issues resolve, but if they have other ongoing issues such as trauma, they can stay on longer in a non-medical bed, where they pay $30 a day. They are not discharged onto the street if they are not ready.
Rooms at the front of the house are for those who are unwell and need closer monitoring, while rooms towards the back are for those who are more independent.
Security is only used at night, but good safety measures have meant there has been very few incidents, which have been well-managed by staff.
As details of the facility have spread among Perth doctors, nurses and other health workers, demand has been increasing.
“It’s been set up so that anyone across any metropolitan hospital can refer to us, not just doctors or EDs, and the more they refer to us appropriately, the more we get the word out,” Ms Thebaud said.
House rules
“We try not to have punitive measures. People can go off-site, but we do ask them to come home in the evening. And while we don’t like to use the word ‘curfew’, we encourage them to be back by 6pm for a hot meal, or back by 8pm.
“We do this because beds are precious, and it’s disruptive to other residents if people are coming back during the night and they’re intoxicated. Having said that, we give everyone a mobile so that if they’re held up, they can stay in touch.
“The building is beautiful, it’s so therapeutic, it’s next to parks, there is so much good about it. Of course, we’re learning what it might look like in the future if we have big personalities, people with lots of trauma, in spaces like this, so that with future funding, it could be purpose-built or renovated to suit them.”
Dr Davies said homeless people had a reduced life expectancy, with 47 the average age of death. People coming out of hospital often had medical issues such as diabetes, post-surgery complications, infections or a combination of medical problems.
It was difficult for people to recover from medical treatment if they were sleeping rough and couch surfing, and some people needed antibiotics that could be stolen from them on the streets.
Dr Davies said it was made very clear to everyone that the facility was not a hospital, but it could help prevent hospital admissions and re-admissions, or visits to emergency departments.
“If we can manage to get people from the streets into hospital, through here and then out to some kind of more permanent accommodation, then it will have a real long-term impact. It’s not just about this admission or preventing the next one,” Dr Davies said.
“It’s about improving people’s life expectancy and making them more functional in society. And while I’m a total realist that many of my patients will never be employed, we have seen a number of people who have gone into employment, and that’s phenomenal.
“It’s not until you start saying that we will look at this altogether and work out where we start and how we do this in some sort of systematic way, that we can start to chip away and see things improve.”
Referrals desirable
Ms Thebaud said that just as the facility was not a hospital, it was also not crisis accommodation.
“There has to be a medical condition, so that’s a big part of us getting out talking to people so they understand what our service is about, so the referrals are appropriate,” she said.
“We can receive referrals from the community to avert someone from going to hospital in the first place – people who are sleeping rough and would more than likely end up in hospital.
“The main goal is to support people out of that cycle of street sleeping or couch surfing, from becoming more unwell and back into hospital.”
The $30 daily fee for non-medical beds was useful in motivating people to look for other accommodation.
“I think people value it more when there’s a monetary contribution, and we do offer financial counselling to help people work out budgets,” she said. “It’s about people having somewhere to recover when they’ve been discharged from hospital. Without this they’d be going somewhere that’s non-compatible with recovery.”
Like with many services, its ongoing funding is uncertain, with the two-year pilot funded until October next year and the results subject to an independent review.
While Dr Davies welcomes the involvement of more GPs, he said getting doctors on board had been ‘the easy bit’, with the main challenge being not only securing government funding but keeping it in the long-term.
“The initial idea started about 10 years ago but it took a long time to get any political traction,” he said. “Now, with the outcomes we’re getting, I think it will be hard for anyone to close the medical beds.”
ED: Doctors and other health professionals wanting more details about the centre can go to www.homelesshealthcare.org.au/medical-respite-centre.