Health services need to better accommodate homeless patients

Health services need to be more accommodating of the needs of their homeless patients, and consider changing how they currently treat the group, the ISR Spring Meeting heard from an expert in the area.

Dr Austin O’Carroll, Mountjoy Street Family Practice, Dublin, and founder of homeless primary care healthcare service Safetynet, gave a thought-provoking and compassionate talk on his experiences of treating homeless people.

Dr O’Carroll explained that about 0.5 per cent of the inner city Dublin population is homeless but they make up 10 per cent of emergency department presentations. They have multiple co-morbidities and frequent addiction issues, and reduced life expectancy; one-in-three have hepatitis C, and one-in-three have attempted suicide, while 25 per cent do not have a medical card.

The focus of Dr O’Carroll’s career has been on improving access for communities affected by marginalisation or deprivation to quality healthcare and he told a number of case study stories to highlight the difficulties this population faces in accessing care. Given their chaotic lifestyles homeless people delay presentation for treatment, often default from care, and do not attend follow up appointments or take their medications.

In the case of one homeless person with a serious rheumatoid condition, Dr O’Carroll detailed their complex struggles to be treated and the results of their not taking appropriate medicines and self-medicating with other drugs.

He noted how afraid and suspicious of healthcare services homeless people can be, leading them to delay presenting to healthcare services until they are very sick.

Dr O’Carroll also explained how waiting to be seen and waiting for the results of various tests is so difficult for these patients. Often the patients have no address to send appointment notices to or have health literacy issues, so when they are marked as ‘did not attend’ they did not know they had an appointment in the first place.

He also highlighted the shame and stigma homeless patients face from healthcare services, recalling a case where a homeless couple with addiction issues presented to hospital emergency services and had been chastised by a clinician for letting themselves get into such a “disgusting” state, which led to them totally disengaging from healthcare services.

Dr O’Carroll explained how he and his colleagues help bring healthcare services directly to the homeless (eg, bringing a hepatitis C treatment clinic to a homeless hostel) and work hard to build relationships and develop trust, detailing attempts at encouraging and supporting these patients to attend hospital services and outpatient appointments when needed, leading to improved outcomes.

Dr O’Carroll suggested that the HSE consider hiring outreach workers who will go out and find homeless people and accompany them to their appointments and he challenged clinicians to try to better reach out to these patients. He also recommended that appointment letters for such patients be sent to services like his, so they can work with the patient to attend the appointment. While some of these moves might be seen as costly, Dr O’Carroll pointed out that earlier intervention in this population would help prevent them presenting so late with expensive-to-treat long-term needs.

In summary, Dr O’Carroll said the current model of healthcare in Ireland is failing homeless patients and there are better ways of delivering care to this population, so the approach needs to change.