Mental Illness, Health

Care and Homelessness

Dr Julian Freidin

Psychiatrist, Homeless Outreach Psychiatric Service, Alfred Health

Director, Mental Illness Fellowship Victoria

Topics

The relationship between mental illness and homelessness

Physical health

The functional implications of mental illness for finding, getting

and keeping housing

Alternative housing models drawing on international practice

Relationship between attitudes and public policy

Critical success factors in collaborative approaches to housing

and support, spanning sectors, disciplines and agencies

Followed by discussion from the floor.

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Health and Homelessness

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The prevalence of mental

disorders among the homeless in

developed countries Meta-analysis of all previous studies

The most common mental disorders are alcohol

and drug dependence, with prevalence

estimates of up to 58%

The prevalence of psychosis ranged between

3% and 42%

The prevalence estimates for depression were up

to 49%

Dual diagnosis 58% to 65%

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Relationships between

homelessness and mental illness

Complex interactions cause a spiral of decline

Mental Illness causes Homelessness (Schizophrenia)

Homelessness causes Mental Illness (Depression, Anxiety, PTSD)

Other issues cause both Homelessness and Mental Illness (Substance abuse)

Complex and severe clinical issues

Fragmented service delivery systems

Many needs

Many services

Interventions should respond to the interaction of biological, psychological, social and cultural factors.

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Homelessness causes and

exacerbates mental illness

In homeless mentally ill people 50% develop mental illness

only after becoming homeless

66% of homeless with substance use problems developed this

ONLY AFTER becoming homeless

Mental illness triggered or exacerbated by:

Constant social and practical instability

High risk of victimisation or assault

Increased physical health problems

Increased substance misuse

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Health Conditions

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Health Conditions

2015-2016 Priorities: Cardiovascular Health

Communicable Diseases

Dental Programs

Hospice/End of Life Care

Smoking Cessation

Sobering Centers

Traumatic Brain Injury

Tuberculosis

Transitions in Care

Specialty Care Resources/Collaborations: Access to Vision, Dental, etc.

Provider Workforce Development & Retention

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Homeless patients at St Vincent’s utilised over four times the

number of acute ward beds when compared with the state

average.

This corresponds to a high burden of mental health, substance

use and physical health comorbidities in homeless people.

There were relatively low rates of linkage with general

practitioner and ambulatory care services.

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Implications for service providers

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Impact of Mental Illness on engaging

with service providers

Basic cognitive (brain) function

Memory, Concentration, Organization and planning skills, Language skills

Mood symptoms

Depression; sad, hopeless, lack of energy and motivation, apathetic, given-up

Anxiety / PTSD; anxious, fearful, scared, avoidant

Psychotic symptoms

Delusional ideas including paranoia; suspicious, irritable, guarded, hostile

Auditory hallucinations; distracted, scared

Personality problems

Emotionally labile, high expectations

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Homeless Survival Skills

Mobile

Don’t trust anyone

Rely on no-one

Avoid rather than resolve problems

Focus on immediate problem

Non-urgent health care is not a priority

High levels of substance use to cope with other stresses

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Difficulties in moving out of

homelessness into housing

Mental illness can affect basic abilities to access and sustain tenancy – including the ability to work through administrative requirements, such as completing application forms, keep appointments, negotiate differences of opinion.

The person’s capacity for independent living may fluctuate and be unpredictable.

People may need assistance with the diverse areas of their lives, particularly if a number of support services need to be coordinated.

When a person is unwell, they may be heavily reliant on others to ensure the availability and coordination of support.

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Problems engaging homeless mentally

ill people

Do not regularly access services or only at times of crisis.

Appear sporadically in drop-in centres, soup kitchens, medical emergency departments.

Enormous problems in engaging homeless mentally ill clients who are living on the streets.

Homeless people have a different idea of their needs than do providers. They believe that meeting basic needs should come first, whereas providers may emphasise mental health or alcohol and drug services

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Need for Early intervention

Severe psychiatric illness tends to be persistent and progressively more disabling.

Similar progression of other problems:

Substance use

Physical health

Sustain accommodation

Social skills

Find and maintain employment

Family support

Insight

Motivation to change

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Challenges to service providers

Tension between needs as seen by the homeless

person and the workers.

Balance needs between clinical and non-clinical

needs (health and housing).

Often issues of changing priorities rather than

absolute needs.

Past failure to adequately address this balance

leads to uncertainty and pessimism.

Who has the authority and the right to decide on

these issues for a homeless person who has severe

and persistent mental illness?

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Models of Intervention for mental

health needs in homeless people

1. Improved Co-ordination

2. Service Linkages

3. Outreach Programs

4. Targeted hospital services

5. Step-down facilities

6. Housing with intensive support

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1. Improved Co-ordination of Local Services

There are multiple agencies addressing issues that include

mental health care,

physical health care,

substance use,

housing,

psychosocial rehabilitation,

daily living needs,

financial support,

legal support.

This silo approach does not work well for people with multiple and

complex needs.

Who is responsible for linking services, and at what political and geographical level?

Danger of creating another layer.

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2. Service Linkages

Formal relationships between mental health and

other providers, including general practice and

housing providers.

Opportunities for mental health services to be

co-located in existing primary care services and

housing agencies where homeless people

attend.

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3. Outreach Health Programs

Major health care provider establishes programs

that work in community and homeless services

locations.

Alfred Homeless Outreach Psychiatric Service

RDNS Homeless Persons Program

Brisbane Homeless to Home Health Care

International Street Medicine Programs

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Service model of HOPS / Outreach Programs

Recognition of the importance of addressing needs as perceived by the person

Assertive outreach with flexible hours

Provision of adequate time to build relationships based on trust

Appropriate responses to unpredictable fluctuations in needs and capacities

Consistent support

Cross service coordination

Planning for crises

Addressing interagency issues

Housing stability

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4. Targeted hospital services

Specialist clinics in the hospital that are mindful of the clinical and other issues for homeless people, and link to other services.

The most common primary diagnoses of adult individuals served by Boston Health Care for the Homeless Program include:

asthma

cancer

depression

diabetes mellitus

gastrointestinal disorders

HIV infection

hypertension

infestations and other skin diseases

pneumonia

tuberculosis

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5. Step-down facilities after acute care

Hospital in the Home programs are dependant on people

having a home.

Medical Respite Care is a US program for homeless people

with physical illness which provides housing for short-term

medical and recuperative services, for homeless people who

are far too sick for life in shelters but not sick enough to

occupy a costly acute care hospital bed.

Boston Health Care for the Homeless is the largest facility with

104 beds, the Barbara McInnis House located on the campus

of Boston Medical Center. Other cities have facilities with less

than 10 beds.

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6. Housing

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Models for housing people with severe

mental illness

Nothing

Institutional care

Stepped housing

Housing First

Congregate or scattered site

Funding models

Integration of housing and health teams

Aim for stability or recovery

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Doorway: An Enhanced Housing First Project

A local example of the impact of housing to improve

health is the Mental Illness Fellowship Victoria Doorway

Project.

Annual cost of $1 million for 50 homeless people who

have severe and persistent mental illness, providing

housing rental support and psychiatric recovery support.

Initial 3 year pilot, recently funded for 4 more years.

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Doorway: 3 yr pilot of Housing First

Goals:

Provide housing and support for 50 homeless people who have severe and persistent mental illness

Provide rental assistance (above 30% of their income) and assist the person develop ways to meet the shortfall themselves, including obtaining paid employment.

Empower people to design their own integrated support team from a range of core and flexible options to live successfully in their chosen home.

Assist people to develop and extend their informal social networks.

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Model differences to Housing First –

Pathways To Housing New York

Private rental with residents signing a lease

Partnerships with Adult Mental Health Services

Partnerships with real estate agencies to secure

properties in scattered sites within three areas in

metropolitan Melbourne and rural Victoria

Housing & Recovery Workers with no clinical role,

with a 1:6 ratio of staff to residents

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Health Outcomes

Average decrease need for each participant for

psychiatric beds from 20 days to 7 days annually

Decrease in annual emergency department

presentations for the cohort of 50 people from 93 to 63

Decrease in annual hospital admissions for the cohort of

50 people from 22 to 6

Shift from crisis driven health care to normal general

practice health care

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Housing outcomes Most participants reported feeling more independent,

having greater levels of self-respect and pride and finding

greater meaning in their lives

6 lease breaks by participants, 10 breach of duty notices

and no evictions

Most participants are able to manage their rents with only

11 people falling into rental arrears.

Ten people currently pay their own rent in full having attained self-sufficiency by acquiring housemates, having

family members move in and by re-establishing stable

relationships with an employed partner.

The mean rental gap paid by Doorway to participants is $194 per fortnight

Many Doorway participants have developed the skills

required to sustain their own private rental tenancies

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International comparison

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International differences

A developmental issue

Relatively few homeless people living on the streets in Australia compared to North America

Mental health and social issue rather than a criminal problem

Universal health care and social security

Different community attitudes and social systems

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Different ideas about homelessness

and mental illness

Mental health problem, social or criminal problem

Individual or collective responsibility

Right to mental health care and right to refuse

Public awareness and interest

Stigma

Political cycle

Input from consumers and carers in service development

Who has the right to advocate

Outcome measurement and accountability

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Conclusions

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Mental illness disrupts an individual's

capacity to think clearly and to relate to

others, which significantly impairs their

ability to negotiate through complex

systems.

The current service system is chaotic,

involving federal government agencies,

state government agencies, and non-

government organisations including the

charitable sector and volunteer

organisations.

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Any attempt to address the needs of homeless people with mental illness needs to shift from a "health" model of care to an integrated model that addresses the broad range of social problems alongside the health problems.

Targeted mental health services to homeless people must be integrated with housing services, but also need to be linked with primary care, physical health services, rehabilitation services, employment services, financial support services, substance abuse services and the justice system.

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