Older Homeless People meeting their continuing health care and support needs

1. Older Homeless People � meeting their continuing health care and support needs Sarah Gorton UK Coalition on Older Homelessness

2. Homeless Link manages: Homeless Link National membership agency for organisations working with homeless people UK Coalition on Older Homelessness - a project aimed at raising awareness of the needs of older homeless people and improving services Homeless Link is a national membership agency for agencies working with homeless people around the country. The UK Coalition on Older Homelessness,is a project aimed at raising awareness of the needs of older homeless people and improving services for older homeless people. In the presentation I have concentrated on the issues facing vulnerable older homeless people and some of the changes that are needed. Rather than look at existing services I am going to concentrate on new practice we would like to see put in place. Homeless Link is a national membership agency for agencies working with homeless people around the country. The UK Coalition on Older Homelessness,is a project aimed at raising awareness of the needs of older homeless people and improving services for older homeless people. In the presentation I have concentrated on the issues facing vulnerable older homeless people and some of the changes that are needed. Rather than look at existing services I am going to concentrate on new practice we would like to see put in place.

3. Case study -Tom Became homeless in forties when marriage ended. Slept rough and in hostels frequently evicted, aggressive behaviour linked to heavy drinking. Liver failure, severe anaemia, needs prompting with personal hygiene, eating and medication. Assessed and placed in residential care, could not settle and left. Highly vulnerable-multiple interacting physical and mental health and alcohol problems. Tom returned to the hostel where he had been formerly. Hostels , designed as temporary accommodation with low level housing related support end up supporting older people with complex needs for whom there is nowhere else to go. Tom returned to the hostel where he had been formerly. Hostels , designed as temporary accommodation with low level housing related support end up supporting older people with complex needs for whom there is nowhere else to go.

4. Numbers and definitions: In relation to homeless people, due to premature ageing issues, we tend to define older people as those over 50 years of age. People who have been long term homeless have often sustained lasting damage to their health through their life style and/or alcohol dependence In the 1990�s the average age of death for a rough sleeper was 42 years In relation to homeless people, due to premature ageing issues, we tend to define older people as those over 50 years of age. Premature ageing tends to be an issue in people who have been long term homeless. Research in the 1990�s showed the average age of death of a rough sleeper was 42 years so it makes sense to start to define older homeless people at a younger age. In relation to homeless people, due to premature ageing issues, we tend to define older people as those over 50 years of age. Premature ageing tends to be an issue in people who have been long term homeless. Research in the 1990�s showed the average age of death of a rough sleeper was 42 years so it makes sense to start to define older homeless people at a younger age.

5. Numbers: There are an estimated 42, 000 older homeless people in the UK. This figure covers: People over the age of 50 who are sleeping rough - an estimated 300 (in England.) Hostel dwellers- an estimated 5, 000 People living in Bed and Breakfasts, an estimated 12,000 An official number of 4,420 people accepted as statutorily homeless and vulnerable due to old age People about to be discharged from prison or hospital with nowhere to go. � There are an estimated 42, 000 older homeless people in the UK[1]. This figure covers: People over the age of 50 who are sleeping rough - an estimated 300 (in England.) Hostel dwellers- an estimated 5.000 People living in Bed and Breakfasts, an estimated 12,000 An official number of 4,420 people accepted as statutorily homeless and vulnerable due to old age People about to be discharged from prison or hospital with nowhere to go. Over half the number, 24, 000 are hidden homeless, living with friends or family, where they have no entitlement to occupy and the house is overcrowded. [1] Coming of Age, J Pannell UK coalition on Older Homelessness 2004 These figures are based on an estimate of any one night rather than over the year. There are well known problems with the rough sleeper counts. These are specifically difficult in relation to the older homeless population. Older people sleeping rough frequently hide from view and are not easily identifiable. There are an estimated 42, 000 older homeless people in the UK[1]. This figure covers: People over the age of 50 who are sleeping rough - an estimated 300 (in England.) Hostel dwellers- an estimated 5.000 People living in Bed and Breakfasts, an estimated 12,000 An official number of 4,420 people accepted as statutorily homeless and vulnerable due to old age People about to be discharged from prison or hospital with nowhere to go. Over half the number, 24, 000 are hidden homeless, living with friends or family, where they have no entitlement to occupy and the house is overcrowded. [1] Coming of Age, J Pannell UK coalition on Older Homelessness 2004 These figures are based on an estimate of any one night rather than over the year. There are well known problems with the rough sleeper counts. These are specifically difficult in relation to the older homeless population. Older people sleeping rough frequently hide from view and are not easily identifiable.

6. Health problems: November 2004 St Mungo�s survey of rough sleepers and those in hostels over 50 years of age: 56% are alcohol dependent 48% have mental health problems 47% have physical health problems 27% have challenging behaviour Health problems Homeless people, and in particular the older population suffer from some of the worst health inequalities of any population group. The severity of health problems depends on how long term they have been homeless and what their living conditions are. A St Mungo�s[2] survey of people sleeping rough and hostel dwellers showed that in those over 50 years of age 56 % are alcohol dependent, 48% have mental health problems, 47 % have physical health problems, 25% have challenging behaviour issues. Physical health problems are exacerbated by age, lack of treatment, poor nutrition, heavy drinking, risk of assault, and for those sleeping rough exposure, hypothermia, and frostbite. Infections spread quickly in hostels and people are susceptible to gastroenteritis, tuberculosis, and skin infestations. It is this picture of complexity and multiple needs which is very characteristic of the older homeless population and which statutory services are ill equipped to cope with. [1] Dying for a home Crisis [2] 50-50 The Big survey St Mungos 2004 [3] Multiple Needs Bevan P and Van Doorn A Health problems Homeless people, and in particular the older population suffer from some of the worst health inequalities of any population group. The severity of health problems depends on how long term they have been homeless and what their living conditions are. A St Mungo�s[2] survey of people sleeping rough and hostel dwellers showed that in those over 50 years of age 56 % are alcohol dependent, 48% have mental health problems, 47 % have physical health problems, 25% have challenging behaviour issues. Physical health problems are exacerbated by age, lack of treatment, poor nutrition, heavy drinking, risk of assault, and for those sleeping rough exposure, hypothermia, and frostbite. Infections spread quickly in hostels and people are susceptible to gastroenteritis, tuberculosis, and skin infestations. It is this picture of complexity and multiple needs which is very characteristic of the older homeless population and which statutory services are ill equipped to cope with.

7. Social exclusion The majority of older homeless people have a combination of those issues, with 43% having 4 or more problems. 74% had no next kin of details Of 36% who are known to be parents 52% have no contact with their children . 23% have no social network Many of the health problems overlap and the majority of older homeless people have a combination of those issues with 43% having 4 or more problems in addition to homelessness. To move to the more social factors affecting older homeless people- 74% had no next kin of details Of 36% who are known to be parents 52% have no contact with their children . 23% have no social network On any definition of social exclusion homeless people will score highly. Many of the health problems overlap and the majority of older homeless people have a combination of those issues with 43% having 4 or more problems in addition to homelessness. To move to the more social factors affecting older homeless people- 74% had no next kin of details Of 36% who are known to be parents 52% have no contact with their children . 23% have no social network On any definition of social exclusion homeless people will score highly.

8. Access to health issues issues: Tudor Hart first described the inverse care law in 1971. It states that the availability of good medical care tends to vary inversely with the need for it in the population served. Unfortunately despite the current emphasis on addressing inequalities in health this still holds true for the homeless population. Tudor hart J (1971) The Lancet 405-12 Tudor Hart first described the inverse care law in 1971. It states that the availability of good medical care tends to vary inversely with the need for it in the population served. Unfortunately despite the current emphasis on addressing inequalities in health this still holds true for the homeless population. Tudor Hart first described the inverse care law in 1971. It states that the availability of good medical care tends to vary inversely with the need for it in the population served. Unfortunately despite the current emphasis on addressing inequalities in health this still holds true for the homeless population.

9. Access to health issues: There are a number of interlinked factors; lack of understanding and awareness on the part of GP practices, discrimination and prejudice, a mistaken belief that people need a permanent address in order to register with a GP A lack of resources and training to address the complex problems presented by homeless people with complex needs Homeless people�s difficulty in using mainstream services, due to low self-esteem, expectation of rejection and difficulty in keeping to appointments. Accessing both primary and secondary health care is problematic for homeless people. Work by Crisis [1]showed that homeless people are up to 40 times more likely not to be registered with a GP than members of the general population. The reasons for poor access are not straightforward. There are a number of interlinked factors; lack of understanding and awareness on the part of GP practices, discrimination and prejudice, a mistaken belief that people need a permanent address in order to register A lack of resources and training to address the complex problems presented by homeless people with complex needs Homeless people�s difficulty in using mainstream services, due to low self-esteem, expectation of rejection and difficulty in keeping to appointments. These factors carry different weight in different circumstances but all have a part to play. These difficulties in access mean that A&E is sometimes used for primary care problems; this is an expensive option for the health service and not satisfactory for homeless people as they get no continuity of care. Access to support and care in relation to drug and alcohol problems and mental health problems is also an issue. Services tend to be organised around a single issue. Mental health teams are set up to provide a service for those with a severe and enduring mental illness. In many homeless people where there is heavy alcohol use it can be hard to distinguish if there is an underlying mental illness. Mental health teams often will not assess people until the alcohol issues are addressed, so leaving people untreated. Personality disorder and challenging behaviour are other labels commonly given to homeless people, which exclude them from treatment. These barriers to care and support can mean that someone with multiple and complex needs who requires a support package is instead living on the streets or in a low support hostel or their own housing and relying on low level support provided by a day centre or tenancy support team. [1] Critical Condition Vulnerable single homeless people and access to GPs Crisis 2002 � [2] Access to general practice for people sleeping rough Pleace N et al (1999) Centre for Housing Policy. University of York. Accessing both primary and secondary health care is problematic for homeless people. Work by Crisis [1]showed that homeless people are up to 40 times more likely not to be registered with a GP than members of the general population. The reasons for poor access are not straightforward. There are a number of interlinked factors; lack of understanding and awareness on the part of GP practices, discrimination and prejudice, a mistaken belief that people need a permanent address in order to register A lack of resources and training to address the complex problems presented by homeless people with complex needs Homeless people�s difficulty in using mainstream services, due to low self-esteem, expectation of rejection and difficulty in keeping to appointments. These factors carry different weight in different circumstances but all have a part to play. These difficulties in access mean that A&E is sometimes used for primary care problems; this is an expensive option for the health service and not satisfactory for homeless people as they get no continuity of care. Access to support and care in relation to drug and alcohol problems and mental health problems is also an issue. Services tend to be organised around a single issue. Mental health teams are set up to provide a service for those with a severe and enduring mental illness. In many homeless people where there is heavy alcohol use it can be hard to distinguish if there is an underlying mental illness. Mental health teams often will not assess people until the alcohol issues are addressed, so leaving people untreated. Personality disorder and challenging behaviour are other labels commonly given to homeless people, which exclude them from treatment. These barriers to care and support can mean that someone with multiple and complex needs who requires a support package is instead living on the streets or in a low support hostel or their own housing and relying on low level support provided by a day centre or tenancy support team.

10. Hospital discharge: Research with homeless people over the age of 50 years in Manchester showed a hospital admission rate three times greater than the national average for people between the ages of 65 �79 years, despite the fact that the average age of the homeless group was 16 years lower. Research in Bristol found a highly increased rate of re-admission in patients living in hostels (35%) to those being admitted from their own home (10%) Research with homeless people over the age of 50 years in Manchester showed a hospital admission rate three times greater than the national average for people between the ages of 65 �79 years, despite the fact that the average age of the homeless group was 16 years lower. 42% of the homeless sample had at least one admission to either a general, psychiatric or detoxification ward in the preceding year. [1] This high rate of hospital admission demonstrates the opportunity that in-patient treatment can provide for making contact with older homeless people and linking them into services in the community. Unfortunately this opportunity to make positive interventions in a homeless persons life following a stay in hospital is often not taken. Homeless people often discharge themselves before re-housing options are addressed. Hospital can be an uncomfortable and alienating environment for people who are homeless and particularly for those who are dependent on alcohol or drugs.Research with homeless people over the age of 50 years in Manchester showed a hospital admission rate three times greater than the national average for people between the ages of 65 �79 years, despite the fact that the average age of the homeless group was 16 years lower. 42% of the homeless sample had at least one admission to either a general, psychiatric or detoxification ward in the preceding year. [1] This high rate of hospital admission demonstrates the opportunity that in-patient treatment can provide for making contact with older homeless people and linking them into services in the community. Unfortunately this opportunity to make positive interventions in a homeless persons life following a stay in hospital is often not taken. Homeless people often discharge themselves before re-housing options are addressed. Hospital can be an uncomfortable and alienating environment for people who are homeless and particularly for those who are dependent on alcohol or drugs.

11. What are the solutions?: