Ireland’s homeless crisis is having an impact on acute care, but one pioneering consultant is ensuring that the most vulnerable patients in her care don’t fall through the gaps.
Dr Cliona Ní Cheallaigh is a consultant in general medicine and infectious diseases at St James's Hospital in Dublin and through her own initiative and personal dedication to homeless patients, she is also one of the world's first consultants working in inclusion health.
Inclusion health recognises the complex medical and psychosocial needs and health inequalities experienced by people from the most marginalised groups such as the homeless, asylum seekers, prisoners and Travellers.
Studies have shown that compared to the general population, homeless people suffer from an increased number of complex medical and psychiatric conditions and as a result are more likely to need acute care. They also have more Emergency Department (ED) visits, longer inpatient stays and use an estimated 20 times more hospital bed days.
Due to the chaotic nature of their lives and lack of support, homeless patients also frequently leave ED without being assessed, leave hospital against medical advice and fail to attend outpatient appointments.
Despite representing just 0.4 per cent of the catchment population of St James’s Hospital , homeless people account for almost 10 per cent of ED attendances and medical inpatients.
According to Dr Ní Cheallaigh, as with St James's, other hospitals in the Dublin Mid-Leinster Hospital Group are also seeing increasing numbers of homeless patients. The social work department in Tallaght Hospital estimates that they are seeing five to 10 homeless adults per week, with similar complex cases presenting frequently to the ED. The Coombe Women and Infants University Hospital is also seeing increasing numbers of homeless women in their maternity services.
Over the past two years, there have been up to 20 homeless inpatients in St James’s Hospital at any one time, with an average of two homeless patients per month experiencing significantly delayed discharge by up to 12 months. A lack of suitable step-down accommodation for homeless patients once they are discharged from hospital can also mean that they are more likely to need re-admission.
Dr Ní Cheallaigh has just completed a 12-month Inclusion Health pilot project in St James’s Hospital in Dublin where together with nurse Ann Marie Lawlee, she has successfully reduced the rates of admission, re-admission and length of stay of homeless patients in the hospital.
For the first six months of the project, Dr Ní Cheallaigh worked on the general medical rota at the hospital seeing patients and she would also take over the care of any homeless patients admitted to the hospital. During the second six months, she balanced an academic role at Trinity College in Dublin with a consultant service to homeless patients in St James's.
Complex needs
The Inclusion Health Service would be notified whenever a new homeless patient was admitted to the hospital and Dr Ní Cheallaigh or Anne Marie Lawlee would visit them and take responsibility for their needs. These could range from very basic requirements such as a clean pair of pyjamas, to more complex needs such as ensuring they had any medication they needed for their stay such as methadone. Crucially, they also worked with homeless services to ensure that patients were not simply abandoned on discharge, and received the supports they needed to reduce the risk of readmission and maintain recovery.
Dr Ní Cheallaigh explained that over the 12 months of the project she embraced a number of approaches to caring for homeless patients, which have proven to work well.
One of these is what is known as a “psychologically informed approach” where the psychological and emotional needs of patients are taken into into account.
“If you look at people who are homeless or other marginalised groups, the amount of trauma they have suffered in their lives is huge. A lot of them, probably up to three-quarters, have had severe sexual or physical abuse in childhood and in a way, more damaging is the neglect. They haven’t had a parental figure to help them feel safe and loved and regulate their emotions. I would see that that is the route of all the behaviours and difficulties in addiction, difficulties interacting with other people and difficulties in interacting with health services,” Dr Ní Cheallaigh explained
“In my view, the primal human need is to feel loved and accepted and until you have that you are not going to be able to address taking your hepatitis C treatment or whatever it is. So we really try to provide a service that within professional boundaries, provides that personal warmth,” she added.
“We go and see them. We give them clean pyjamas, make sure their methadone is sorted out, give them a friendly face, say hello, make them feel welcome, it is so simple and it makes such a difference and it doesn’t cost much. All patients should have that. It is just making sure that those who are least likely to get it, definitely get it,” Dr Ní Cheallaigh explained.
“Clean clothes in a public setting – it is a basic human right,” she said.
Dr Ní Cheallaigh also paid huge credit to the person responsible for renting televisions to patients in St James’s who provided them for free to homeless patients.
It may seem like a very simple thing, but when you consider that a number of homeless people may have literary challenges such as difficulties with reading, access to a television during a stressful hospital stay can be a lifeline.
Discussing patients
As part of the project, Dr Ní Cheallaigh held weekly multidisciplinary interagency meetings with staff in the Merchant's Quay Ireland Homeless and Drug Services. This involved discussing patients who were in the hospital and needed support on discharge or homeless people identified by the service that might require acute care.
The meeting is attended by key workers, public health nurses and GPs from Safetynet; a charity that provides free primary care services to homeless people. The meetings also serve to break down the professional barriers that can sometimes occur between hospital and community-based care, Dr Ní Cheallaigh said.
She explained that the traditional hospital approach of admitting a patient with an acute infection, for example for a few days on IV antibiotics and then discharging back into homelessness again simply doesn’t work for vulnerable groups. Unless their other complex needs such as addiction or homelessness are met, they are more likely to need re-admission.
In the midst of Dublin’s homeless crisis, the results of the Inclusion Health pilot project in St James’s Hospital are impressive.
“The number of homeless people has gone up in Dublin but the number of homeless people coming into James’s has gone down. We estimate we have saved about 200 admissions and about 2,000 bed days in the year’s pilot,” Dr Ní Cheallaigh explained.
One of the biggest challenges faced by the project has been the lack of appropriate step-down accommodation for homeless patients once they are discharged from hospital.
“They have had a stroke so they are going to need somewhere that is wheelchair accessible or where a toilet is accessible – the problem is there is such a shortage of accommodation.”
Dr Ní Cheallaigh explained there was a lack of hostels where recently discharged patients could stay and recuperate during the day. Currently the majority of accommodation available is one-night-only beds, which are closed during the day, and these are not appropriate for people leaving hospital. She said that due to the lack of appropriate step-down care, there was currently a patient in St James’s who has been waiting for discharge for a number of months.
“The lack of appropriate accommodation is huge, it ensures worst outcomes for the patient and it also puts a huge burden on the hospital because we don’t have anywhere safe or appropriate to send them. If we do send them out and it is not appropriate, they tend to come back in,” she said.
The Inclusion Health Service at St James’s Hospital is one of the first of its kind in the world. However funding for Nurse Lawlee’s post has now run out and Dr Ní Cheallaigh’s position is also at risk due to lack of resources.
Dr Ní Cheallaigh said that St James’s Hospital has been hugely supportive of her work. She has recently submitted a business plan to the hospital and is currently awaiting news on whether the service will receive the funding it needs to continue.
According to the business plan, the service would need a consultant, two nurses, a senior social worker and an administrator at a cost of €396,446 a year.
These costs would be offset over time, due to reduced length of stay, reduced admissions of homeless patients and the resulting reduction in bed days. It would also position St James’s Hospital and indeed Ireland as a centre of excellence in the provision of care, education and research in Inclusion Health.
Conference
Dr Ní Cheallaigh spoke at the 3rd Irish Street Medicine Symposium which took place in UCD on September 29th and 30th last. The conference was organised by Safetynet and UCD, with support from the HSE National Office for Social Inclusion.
Dr Austin O’Carroll, co-founder and medical director of Safetynet, said that the service Dr Ní Cheallaigh had developed in St James’s was “incredibly valuable” and had “dramatically transformed the healthcare of homeless people in hospitals”.
“Her service has not only produced more humane care but it has also reduced the amount of time homeless people spend in hospital. Homeless people wait until they are so sick they have to go to hospital but then because they don’t feel comfortable in hospital, they don’t feel their needs are being met so they leave early before the treatment is completed. They have a shorter stay but then they end up being re admitted two or three weeks later. So what Cliona has done by addressing their needs means they stay longer, get the treatment and don’t get re-admitted,” Dr O’Carroll said.
The Minister for Health, Simon Harris, also attended the symposium where he officially launched a new mobile health unit operated by Safetynet and Dublin Simon, which provides a free primary care service to rough sleepers in Dublin.
Addressing the conference, Mr Harris acknowledged the need for step-down facilities for homeless people on discharge from hospital.
“We have a bizarre situation now in this country where people who are homeless find themselves trapped in our hospital setting and with nowhere else to go. We obviously need to be in a situation whereby we can look after somebody’s health needs but when they are ready to be discharged from the hospital they do obviously need continued support, have a supportive environment in which to send them, and I think we can make great progress together on this during 2018,” the Health Minister said.
He also committed to increase funding for homeless health services in 2018.
Speaking to reporters at the conference, Minister Harris said he was supportive of the work being done by Dr Ní Cheallaigh in St James’s and he would like to see the Inclusion Health Service extended to other hospitals.
“In our health service we have many extraordinary doctors, but in Dr Cliona and St James’s we have seen a doctor who has gone above and beyond in terms of coming up with new and innovative ways for caring for some of our most vulnerable patients, often homeless people. I think it is very important that what she is doing is fully supported and supported on a sustainable and long-term basis,” the Minister stated.
n Dr Ní Cheallaigh is due to speak at the upcoming St Luke's Symposium at the RCPI, which takes place from October 18th to 21st at 6 Kildare Street in Dublin. At the symposium, Dr Ní Cheallaigh will speak on premature ageing in homeless populations. As part of the symposium, the RCPI is also hosting a public meeting on Thursday, October 19th, entitled "Ageing Well in the 21st Century". This event will be led by former Minister Mary O'Rourke and will include talks on mindfulness, men's health, exercise and nutrition. See rcpi.ie
