1 Transforming Healthcare for Homeless People: The Value of Occupational TherapySophie Koehne Dan Lescure John Sapani KHP Pathway Homeless Team

2 Session outline Homelessness: the Context The Pathway approachHomelessness: health and Social issues Why OTs? Experience of establishing roles Service Evaluation Case studies Sophie

3 What is homelessness? Homelessness is about more than rooflessness. A home is not just a physical space, it also has a legal and social dimension. A home provides roots, identity, a sense of belonging and a place of emotional wellbeing. Homelessness is about the loss of all of these. It is an isolating and destructive experience and homeless people are some of the most vulnerable and socially excluded in our society. (Crisis) Includes: Rough sleeping, in Temporary Accommodation, Sofa surfing, Squatting, Facing eviction Long term homeless Recent or sudden homelessness Sophie

4 Homelessness: the contextHomelessness Reduction Bill 2017 Homelessness: a silent killer (Crisis, Dec 2011) Healthcare for Single Homeless People (Department of Health 2010) “high quality, integrated services that meet their health needs” (St Mungos, 2016) Turned away (Crisis, Oct 2014) Sophie Current Evidence – Danny Dorling, Andrew Hayward, Stephen Hwang Homelessness: a silent killer (Crisis, Dec 2011) Average age of death 43 (women), 47 (men) 1/3 of deaths caused by drug and alcohol Homeless people 9 times more likely to commit suicide Health Care for Single Homeless People (Department of Health 2010) Frequent A &E attendance and high cost of unscheduled care (8x that of the cost of housed) Due to tri-morbidity – physical health mental health and substance misuse Improving hospital admission and discharge for people who are homeless (Homeless Link, May 2010) 70% of homeless people receiving hospital treatment were discharged to the streets No one turned away’ (Crisis, Oct 2014) ‘Mystery shopper’ exercise 4 typical stories – a person homeless due to losing their job, a young person thrown out of home, domestic violence, a vulnerable person with learning disabilities In 50 out of 87 cases actors received little or no help Wider issues: Lack of local connection – services are linked to borough Lack of ID/proof of entitlements Specialist knowledge and networks beyond the scope of hospital wards Political policy – reduced welfare, changes to UC, Needs Assessment in 2012 Because of the high cost and prolonged nature of psychiatric admissions the total cost was £2,670,553 annually, nearly a third of the whole costs to KHP.  KHP hospitals were the lead providers of unscheduled secondary care to homeless people in London £9.2 million annual expenditure on emergency care Needs assessment underestimated the actual need of patients with and without a care coordinator.  The service end date is 15th December (Pilot project to try model in MH setting) 3 components, specialist homeless GP supported by clinical and allied health specialists including nurses, social workers and occupational therapists, interdisciplinary workers including Housing workers, care navigators Teams also work closely with community health services, housing, social care and the voluntary sector.  Pathway service has run across a whole Academic Health Sciences Centre – Kings Health Partners, across different hospitals specialising in physical health care and mental health care PHE outcomes framework – incorporated homelessness indicators into their data collection to understand better the social determinant’s of health to help improve and protect health London Homeless Health Partnership: commitment to delivery of better health, and  services for homelessness – commitment 7 MH Julian Corner Root causes of Homelessness are complex, often begin in childhood not everything is quantifiable - we need to challenge the traditional models when helping those with complex needs. Alex Tulloch Residential mobility impacts length of stay in hospital Danny Dorling Public policies, housing insecurity and austerity have an acute and long term effect on health of the population. Rough sleeping doubled in the lifetime of the KHP Pathway Teams Homeless team at SLaM 20% increase in referrals of rough sleepers within a year Al Story Andrew Hayward Considerable health inequality and impact on morbidity and mortality due to extreme exclusion in high income countries –  impact is very sig in mental illness and drug misuse

5 4134 271,000 Attend A&E 5 times as often Are admitted 3 times as oftenCompared to the general population, Homeless people: Attend A&E 5 times as often Are admitted times as often Cost times as much John

6 Homelessness in LondonIncrease of 20% between and and John

7 Reason for HomelessnessImportant to note that most of our referrals are not rough sleepers Outside of central London – hidden homeless and sofa surfers not picked up by traditional collection methodologies John

8 Pathway Approach Homeless people repeatedly discharged & readmitted without proper planning or coordination Impact of homelessness & links to health and addiction may not be recognised by clinical teams Need for integrated pathway for homeless patients Pathway team helps support clinical teams Support collaborative care across health, housing, social and voluntary sector, increasing safe discharge Dan: The team aims to ensure homeless people have the best possible hospital experience and achieve the safest possible discharge outcomes by providing: Homelessness advice Addressing unmet healthcare needs supporting clients to access housing Reintegrate into the community Traditional teams understanding non-trad teams/roles Kings Health Partners: KCH, GSTT & SLaM

9 Non-traditional patient in a traditional setting

10 Health Issues Tri-morbidity Early Aging Late diagnosis and treatment Capacity issues Risk of Falls Substance misuse Brain injury BBV Amputees Respiratory illness Liver disease Cardiac problems Cognitive Impairment Epilepsy/Fits Psychosis Depression Suicidality Personality Disorder Learning disability Unspecified Mental health difficulties Cancer Dental issues Dan: Homeless people have the same health issues as the general population, however can often be more complex due to late diagnosis or difficulties engaging with treatment/services etc Across the top in green we have some overarching issues

11 Social Issues Homeless patients Stigma Difficulty accessing healthcare Social exclusion Recurring patterns of behaviour No ID or documents Transient population Financial problems NRPF Poor communication Poor Life Skills Lack of privacy Dan: The health problems are often addressed, but may not take into account the social issues for this population. The health and social problems are closely linked.

12 Having just a house doesn’t solve homelessness

13 Why OTs? OT Skills Experience of client groupUnderstanding impact of environment Versatility/adaptable Transferable skills Training across physical and mental health Outcomes orientated Advocacy Rapport building – client centred practice Creative use of occupation – enabling (Grandisson et al, 2009) Experience of client group Loss of roles Unstable living Environment Loss/change of Identity Loss of skills Disempowerment Stigma Lack of structured occupation Lack of opportunity Lack of control Lack of Privacy Lack of resources (Chard et al, 2009; Illman et at 2013) Sophie: Lack of control over time and resources available. Loss of control due to destitution and NRPF OTs are well positioned to develop a service in the population due to (Grandisson et al, 2009)

14 Experience of establishing our rolesOT role in MDT Allocation of case load OT ax (appro, added value) Using specific OT skills – (Joint working) Establishing working interface with wards/ward based OT’s Working in this team has raised the profile of OT within homeless and voluntary sector services, whilst simultaneously showcasing the versatility of OT skills within a broader healthcare setting.

15 Experience of establishing our rolesMaintaining OT identity in generic role Setting up service – OT focus in team initial assessment Writing housing support letters with OT focus Providing training to OTs within Trust Peer Support Establishing an OT Network – national interest

16 Experience of establishing our rolesTransitional work Discharge doesn’t mean resolved Linking in New challenges 10 day post-discharge

17 Service Evaluation Reduced Length of StayReduced readmission rates (not across all sites) Developing OT Intervention Outcomes Future Opportunities Inreach into hostels Experts by Experience Expanding OT Network

18 Case study Advocacy OT assessments and interventions:Discharge outcome: Nursing home Challenges:  Advocacy Safe discharge Interface of working with ward OT’s Background: Rough sleeper – Evicted from flat No GP No benefits Health: Multiple Physical health Cognitive impairment (Suffered an RTA) OT assessments and interventions: MoCA (Montreal Cognitive Assessment) Capacity Assessment Assessment of functioning Patient goals: Having somewhere safe to live and support Engaging in music Employment (customer service)

19 Rosie’s story

20 Multi-agency and MultidisciplinarySophie

21 References Crisis. Available at: www.crisis.org.uk (Accessed 16/06/17)Homeless Link. Available at: (Accessed 16/06/17) Turned Away, Crisis. Available at: https://www.crisis.org.uk/media/237024/mysteryshopping_report_final_web.pdf (Accessed 16/06/17) Grandisson, M., Mitchell-Carvalho, M., Tang, V. and Korner-Bitensky, N. (2009) Occupational therapists' perceptions of their role with people who are homeless, British Journal of Occupational Therapy, 72 (11), pp Stop the Scandal, St Mungo’s. Available at: (Accessed 12/01/17) Pathway. Available at: (Accessed 12/01/17) DH (2010) Healthcare for homeless people, London: Department of Health Illman, S., Spence, S., O’Campo, PJ., and Kirsh, B. (2013) Exploring the occupations of homeless adults living with mental illness in Toronto, Canadian Journal of Occupational Therapy, 80 (4), pp

22 References Chard, G., Faulkner, T., Chugg, A (2009) Exploring occupation and its meaning in homeless men, British Journal of Occupational Therapy, 72 (3), pp Thomas, B. (2011) Homelessness: A silent killer - A research briefing on mortality amongst homeless people. London: Crisis.

23 Any Questions? [email protected] [email protected] What Ax do you use? What work do you do in hostels?