Vulnerability Index, Brain Injury and Chronic Homelessness
Felicity ReynoldsCEO, Mercy Foundation &
Chair, Australian Common Ground Alliance
Overview
Some background about terminology. A bit about Hwang’s US research into
brain injury and chronic homelessness.
What is the Vulnerability Index (VI)? What has the VI told us about brain
injury and chronically homeless people in Australia?
What might all this mean?
Traumatic Brain Injury and chronic homelessness
First – why TBI instead of ABI. TBI is more commonly known as acquired brain injury
(ABI) in Australia. I prefer the term TBI, as it more accurately describes
the likely method by which the injury was ‘acquired’. It speaks to the likelihood of a traumatic and, possibly
violent, childhood, as well as the TBIs that can be acquired when you have to cope on the streets and live in unsafe places, the violent experiences of prisons and other institutions and, of course, the experiences of being regularly intoxicated and falling down a lot. These are all ways in which someone might do permanent damage to their brain.
Dr Stephen Hwang’s research Hwang (2007) – a study on TBI with 1200
homeless people. Summary results:
Lifetime prevalence of TBI in a representative sample of homeless people is more than 5 times greater than in the U.S. general population
TBI prevalence among homeless people is within the range reported among prison inmates.
First TBI usually occured prior to the first episode of homelessness History of TBI strongly associated with wide array of adverse health
outcomes. Cognitive consequences of TBI may increase the risk of subsequent
mental health, alcohol, and drug problems. However, pre-existing mental health, alcohol, and drug problems
may increase the risk of experiencing TBI.
Hwang’s – recommendations for service providers Clinicians should routinely screen homeless patients for history of TBI.
TBI should be considered a possible cause of neuro-psychological dysfunction and behavioral problems.
Further efforts should be directed at the management of TBI-related problems such as impulsive behavior, and the treatment of co-occurring alcohol or substance abuse.
Persons with brain injuries may have attention deficits, making it difficult for them to focus on tasks and understand, remember, or respond to directions.
These individuals may need more time to follow instructions; slowness should not be misinterpreted as a lack of effort or cooperation.
TBI-related brain dysfunction can predispose to irritability or impulsivity that should be understood in the context of the person’s previous injury.
The Australian context
Many of you work in organisations that see homeless people daily and you know the context. The following is about a methodology for knowing, doing something and measuring outcomes.
What is the Vulnerability Index? Some of you already know (and have been directly
involved here in Sydney). For those that don’t....it is not an ‘assessment tool’,
it is a practice instrument and methodology for a local campaign to locate chronically homeless people, complete a VI survey to better understand their health and housing needs and then to work with them to achieve a housing goal (PSH – if relevant).
Background about the VI
Huge coincidence! Hwang was actually the co-author of research (done in the 1990s with Dr Jim O’Connell, on which the VI is based). That particular research was broader and looked at all the health vulnerabilities of chronically homeless people.
They found 8 vulnerability factors that put people who were homeless (compared to people who were housed) at greater risk of death.
8 vulnerability factors
6 months homelessness or longer and…… End Stage Renal Disease History of Cold Weather Injuries Liver Disease or Cirrhosis HIV+/AIDS Over 60 years old Three of more emergency room visits in prior
three months Three or more ER or hospitalisations in prior year Tri-morbid (mentally ill+ abusing substances+
medical problem)
If aged under 25
An additional 3 vulnerability factors:
Alcohol everyday in past 30 HIV+/AIDS Injection Drug Use
Quick description of methodology for Registry Weeks and next slide – Registry Week’s with VI in Australia, since 2010.
425
56
148
463321
109
321
1680 people surveyed as at August 2012
158
Summary statistics
76% male 22% female Most of the population surveyed were
between 36 and 55 (54%) years old 23% identified as Aboriginal or Torres Strait
islander.
(Note these statistics don’t include Perth)
Summary statistics
28% had been in foster care 75% had spent time in police cells 53% had been in prison Half (773) of the number surveyed (1522) had
not been housed at all in the past three years 26% had been housed/re-housed 3 times or
more 6% had been housed/re-housed 10 times or
more.(Note these statistics don’t include Perth)
Homeless history
Average age and time homeless - by region
6 10 9 15
76
0
10
20
30
40
50
60
Brisbane Sydney Melbourne Townsville Hobart Western Sydney
Average age Average years homeless
44 45 44 48 38 40
Sample size = 1522
Vulnerability
Australia-wide by region
Brisbane Townsville SydneyWestern Sydney Melbourne Hobart Total Percentage
Sample size 425 56 463 148 321 109 1522 100%
Number of vulnerable 295 36 294 67 204 70 966 63%
Perth (August 2012) Total sample size = 158Number of Vulnerable = 93 (59%)
A few key findings
61% reported a mental health condition 51% reported having received treatment
for a MH condition 73% reported drug/alcohol abuse 46% reported having received treatment
for drug/alcohol abuse 51% had been the victim of a violent
attack 24% reported a disability that limited
their mobility
Brain Injury
29% reported a brain injury or head trauma.
Yes....almost a third of all respondents (with significant histories of homelessness) SELF – reported a brain injury or head trauma.
Hmmmm...........
So, perhaps those chronically homeless people who are ‘treatment resistant’ or ‘non-compliant’ might actually not be able to remember appointments too well. They may have impulse control problems.
Theymay need to be supported in a different way. They may need some extra help to remember things (as just one example).
If suspected, a neuro-cognitive assessment should be arranged.
What else does this mean? All chronically homeless people need
housing to solve their homelessness and some may also need ongoing support to sustain housing (PSH).
This is KNOWN (not guessing) to include almost a THIRD of all chronically homeless people who may have problems caused by a TBI - and require permanent (not transitional) support to sustain housing. (Additional evidence for this need is their current state of long term homelessness.)
Conclusions
Permanent Supportive Housing is the only answer for people with significant TBI and chronic history of homelessness.
Through the VI, we have gained a better understanding of how many (and who they are – and some are now in PSH) in the chronically homeless population may need this type of ongoing support to sustain housing.
In fact, there could also be a number of this population who may require significant (including 24 hour) care (but more specialist assessment information would be needed).
