The Homeless Health Exchange provides a Substance Use/Health Nurse, funded by RSI (Rough Sleepers Initiative) to work in partnership 4 hours a day, which can be flexible and agreed depending on what work is identified at daily tasking meetings with partner agencies.  Working hours can be flexible and if required early morning and late nights can be arranged to target those rough sleepers that may not be visible during the day.

Assertive street outreach relies on partnership working and all organisations should have a clear goal when working together being aware of governance and information sharing and adhering to their organisations protocols.  We work with several housing/support and Substance Use agencies including Trident, Shelter, CGL, Housing First, Rough Sleepers Mental health Team. 

Tasking meetings currently happen three times a week with all agencies and is led by Trident Rough Sleepers Team (RST).  Current rough sleepers are raised and discussed and needs identified, then a brief discussion follows about what agencies need to be involved.  This meeting then governs clearly who will then try and see the person and how this will be done.  Assertive street outreach helps workers build relationships with people in their environment and can increase engagement. The information is collectively gathered and recorded in a ‘handover’ document by RST and then shared daily with all partner agencies.  Pertinent information can also be sent in and added and shared.

Street outreach can be opportunistic as well as targeted. The targeted approach is to specific individuals.  I am typically tasked with engaging with those individuals who have health concerns.  It will offer, those seen on the street, to register with The Homeless Health Exchange and inform them of the benefits of our service.  These patients often have negative experiences or perceptions of GPs such as inflexible approach, negative attitudes of staff and rules about attending appointments and making them.  The process of engaging, building trust and a good rapport are all part of the approach to counteract the belief that all GPs are the same and are rigid with their systems. The HEX offers daily drop-in sessions for those that struggle with appointments and equally, appointments are offered for those that want them and can be at times when the clinic is quieter.

An assessment of health needs can be done and advice can be given and further treatment actions can either be delivered on the street or at the HEX or in acute situations, referred to hospital. Close working and liaison with in-house colleagues at HEX is ongoing and the flexibility of our approach means that support, advice or joint working with a colleague is all part of regular working practice. MDT with the whole priM care team including lead GP’s occurs once a week and there is a weekly Rough Sleepers Mental Health Team MDT attended by the two Health Outreach Nurses, this is an opportunity to review current patients and discuss new referrals.

Joint working is highly effective and allows for other issues to be addressed at the same time, daily outreach is with RST and CGL, but all partner agencies can work together when the need arises. Reviews and professionals meetings take place on a regular basis.  These are especially useful when working with the most complex and hard to reach people and a multi-agency discussion will often provide a strategy for moving forward or to look at a different approach that hasn’t been previously tried.  Minutes are typically recorded by the lead agency and will then share with all the professionals involved in the person’s care.  A brief sumM of these will be recorded on the EMIS notes.  A copy of the notes will also be uploaded on to GP Teamnet.

M (39)

M registered with HEX in 2013 and has been seen intermittently since then. M has a long, complex history of homelessness, substance use, domestic abuse, self-neglect and physical health problems.  Initially she was referred for help with her drinking.  She was alcohol dependent and would have frequent attendances at hospital with issues secondary to her alcohol use i.e. acute withdrawal symptoms including seizures, hallucinations, and alcohol related injuries.  Attendance and meetings were very sporadic as M’s lifestyle was very chaotic.  M lost contact after going to prison.

M came to my attention again when she started rough sleeping in the city centre.  She tended to sleep alone and frequently declined any assistance from the outreach agencies on the street.  A discussion at a tasking meeting identified that her main needs were her drug use, physical and mental health needs, social needs and housing. She disclosed that she was not in receipt of benefits and survived on money from begging.  I saw M most days on outreach and over a period of time started to build a trusting relationship.  We would get her cups of tea and chocolate bars and although she would say she didn’t want any help we would just spend time talking over a cup of tea.  During a period where she developed an infected finger I visited her daily to do the dressing and provided antibiotics – this allowed again time to talk and during this period I think she let down her guard and became more trusting and started to see the benefit of engaging and working together.

At this time, it became apparent that she was in a volatile relationship and the victim of mental and physical abuse.  An element of the psychological abuse was her partner being very controlling and would exact this through withholding drugs and allowing her to go into withdrawal.  A targeted approach was to visit her with CGL and to see if we could get her into drug treatment and this would give her back some control around drug use and managing her withdrawals.  Through this outreach we were able to facilitate an appointment with the CGL medic and get her started on a methadone script.  She was referred to a Domestic Abuse Team and discussions took place with the police for advice, being extremely cautious to maintain confidentiality, not put her at further risk and not to do anything she didn’t want to do.

M was referred to Shelter for help with benefits and to think about longer term options for housing.  In the meantime, RST offered accommodation options daily, however M was reluctant to go into a hostel.  A referral was made to Housing First.  Over the course of the next 12 months we all continued to engage and work with M, which included joint outreach, regular MDTs, a referral to Social Services where a safeguarding was raised and a social worker allocated.

We all continue to work with M and although she has come a long way, there is still work to do and we are going at her pace.  She has recently agreed to a referral to mental health, she has always said that she needs to work through painful past issues but not been ready, so to say that she is ready to start talking is huge progress.  We are hoping that in the not too distant future she will move into her own Housing First property.  I continue to support her around health issues and she has remained in treatment with CGL and on a methadone script for the longest period ever for her.