Serving the homeless population in Cork

A multidisciplinary team which focusses on providing vital services to isolated and secluded individuals caught in the throes of homelessness, was presented by Dr. Anna Marie Naughton of the Adult Homeless Integrated Team (AHIT), Cork Kerry Community Healthcare St. Finbarr’s Hospital, Cork.  Maureen Browne reports.

Anna Marie Naughton
Anna Marie Naughton

She said it is the only multidisciplinary team of its kind in the HSE providing a full spectrum of addiction, mental health, and medical services on an in-reach and assertive outreach basis to the homeless population in Cork. It works closely with community-based services, secondary and tertiary care and statutory or voluntary agencies.

Dr. Naughton said they were predominately working with Cork Simon Community and St. Vincent de Paul.  The team was a bi-product of ‘Homeless in Cork,’ which found that adults experiencing homelessness were faced with greater health issues and that dedicated services were needed to assist them onsite.

The AHIT includes a project manager, nurse, GP, part time psychiatrist, two community mental health nurses, mental health social worker, part time clinical psychologist, three addiction counsellors, opiate substitution GP and administrative support.

“We provide nurse and GP led clinics, specialist mental health and addiction services including opiate substation therapy in a multidisciplinary team model which are all on a low threshold basis,” said Dr. Naughton.

This team has developed numerous innovative channels and initiatives to enhance or streamline services.

“Clients feel secure, seeing a consistent person and being able to engage with them. The reality is that these are patients who are unable to successfully access mainstream services and the provision of in-reach services is the only way many of our patients can access appropriate health care. Many people who are homeless are ashamed and embarrassed about their status and we are aware of this and sensitive to this.

“The main objective of AHIT is to meet the complex needs of homeless service users who would otherwise fall through the gaps in community care and miss out on necessary treatment. Identifying these gaps, we create effective solutions to improve clients’ physical and emotional well-being, building the capacity of these clients to eventually reconnect with services in the greater community. Thus, this team has developed numerous innovative channels and initiatives to enhance or streamline services, and have increased engagement with people that would traditionally show great difficulty in accessing or maintaining treatment.

“AHIT departs from existing models of care and takes a pragmatic approach to provision of services. The AHIT focuses on providing vital services to isolated and secluded individuals caught in the throes of homelessness. While there are many teams serving the homeless population across Ireland, AHIT stands alone in its span of clinical proficiency, specialist advocacy and coordination of care, pioneering effective service provision and fusing robust and integrative expertise.

“It is built on the premise of ‘meeting the patient where they are at’ and involves relationship building both with the clients/ patients and the other agencies with which they interact. As a team we have a significant working knowledge of where our patients are coming from and the various agencies they are dealing with.  This allows us to help our patients to navigate their way through the various services they need.

“There is a respect for our clients and an understanding of the often difficult lives that have led them to this point. The development of trust is central to being able to help this population who often suffer the multiple disadvantages of mental illness, severe addiction and poverty. They live the day to day reality of the ‘inverse care law.’ They team is concerned with ongoing learning both from each other and are open to learning from our clients.”

Dr. Naughton said they were very aware of the need to integrate with existing services and not become a cul de sac where patients lingered and lost the opportunity to reengage with mainstream services.

The main objective of AHIT is to meet the complex needs of homeless service users who would otherwise fall through the gaps in community care and miss out on necessary treatment.

“Our dual aims are to support patients back into mainstream services and to provide specialist services for the cohort for whom that remains too difficult. Especially our rough sleeper and long term homeless clients who often have severe and enduring mental health issues with chronic addiction.

“This is not a team that arose overnight. One of the lessons learned is that something like this takes time to grow and evolve. The issue for our patient population is fundamentally one of access and by providing services in the actual hostels and taking the time to develop the relationships both within the team, with patients, keyworkers and other services.

“Communication is a major barrier, our patients by definition have no fixed address and this simple factor often results in them being lost to follow up.

“The simple fact that our nurse has a good relationship with the specialist hepatology services and maternity services has greatly improved attendance at these clinics. SafetyNet primary care has been a longstanding partner to the AHIT team and has provided IT support in the form of a national network of GP software to improve patient care and follow up.”

She said that providing in-reach services required a high level of coordination and day to day contact with hostel staff, keyworkers, community drug workers, probation, residential addiction services, local hospitals, GPs, pharmacies, department of social protection and addiction services. They had named basis interactions with these organisations and were a first port of call for many when trying to coordinate the care of someone who is homeless.

Since the start of this initiative, the number of overdoses within Cork Simon Community clients has decreased by half compared to 2015.

A recent example was a patient with longstanding alcohol addiction and hepatitis C infection. He became very unwell and they referred him for admission. They had been coordinating his appointments with hepatology prior to this. “He was in liver failure and improved with treatment and was due for discharge but would have been discharged to the streets where he would have relapsed in his drinking and probably died. Working with the outreach and housing in Cork Simon, the nurse specialist, consultant in hepatology and his doctor in the addiction services, we were able to delay the discharge until appropriate accommodation in Simon was arranged and he has maintained his abstinence and is doing well. In the last two weeks he has been approved for Hep c treatment – only one of four for whom funding has been allocated on the basis of how ill he was. He was seen by our nurse this morning and has been doing very well.  We have been coordinating and negotiating that he remains in supported accommodation whilst he completes his treatment. This all works due to the good working relationships we have built.

“To solve the difficulty of follow-up care with people that lack a permanent address, AHIT are developing discharge policies with A&E and hospitals to ensure continuity of care and treatment. Through such programs and initiatives, AHIT builds beneficial therapeutic relationships with clients.  Treatment outcomes are further improved by virtue of various disciplines operating under the same roof. There is a high regard amongst service users, they will trust our nurse’s word as they know her and they know she will be there for them next week.

“Many of our patients have a significant history of trauma and we have completed research with Dr Sharon Lambert from the department of applied psychology in UCC on the prevalence of adverse childhood experiences in this population. We are currently looking at the logistics of being a “trauma informed service.” ACE study, Cork Simon, UCC, AHIT

Dr. Naughton said that many of their IV drug using population were Hepatitis C positive. “We are involved in regular screening and safe injecting practices and our most recent population screening showed a Hep C rate of c. 17%, below the expected level for this population.

“One new initiative created was the methadone induction program (MIP) which enables clients to obtain necessary methadone within a regulated system in-house, presenting fewer obstacles than when using a community methadone clinic. This multifaceted system includes clinical assessments, psycho-educational sessions on harm reduction and treatment options, urinalysis, and methadone administration, and is achieved with clear coordination between the GPs, nurse, and addiction counsellors. As a result of the programme’s effectiveness, methadone substitution treatment has increased to where now nearly 90% of clients needing treatment have availed of it, compared to the 10% previous to the initiative.

Additionally, since the start of this initiative, the number of overdoses within Cork Simon Community clients has decreased by half compared to 2015.

Counselling attendance rates for have maintained an unprecedented average of 69-71% across 2016 (general counsellors experience a rate of 72 -79% without such a vulnerable and chaotic client base). The consultation rate for the nurse and GP is approximately 3,000 consultations per year. In 2015, Partnership for Health Equity and North Dublin GP training scheme organised the first Irish Street Medicine Symposium in Dublin with a plan to hold one biannually. Recognising the value of such an event, AHIT proposed to hold a 2016 conference in Cork and, as a team, took on the function to organise the event with UCC’s department of general practice. Irish street med symposium-2016

Almost 200 people from Ireland and the UK attended and over 45 speakers presented. Topics included parenting in homelessness, mental health outreach, and palliative care. AHI team members ran workshops on trauma-informed practice and ethical dilemmas in mental health.

“Because of AHIT’s proposal, the symposium will now run annually, ensuring practitioners and staff can be kept up-to-date with best practices in homeless care provision. We were also part of the organising committee for the 3rd Irish street medicine symposium and presented at it.

“We also have links with training and education. Medical, nursing, psychology and social work students have placements with us. We deliver educational pieces in UCC and to GP training and GP trainees attend sessions with us. This allows exposure to this cohort for new GPs who might otherwise have had negative attitudes to our clients.”

“Fundamentally there is huge respect for patients, and this translates into being able to build relationships and advance the therapeutic journey for this complex population.”