Homeless Health Peer Advocacy (HHPA): Empowering Lives Through Health Support

1. Death on the Streets Martin Murphy and Suzy Solley (Groundswell) 26th Sept 2019

2. At Groundswell we enable people experiencing homelessness to take more control of their lives, have a greater influence on services and have a full role in our community. We do this in three ways: • Homeless advocacy this includes HHPA and in-reach • Peer research • Peer progression

3. 70% of our staff have been homeless – lived experience is at the heart of Groundswell. 12 from vol to staff.  • In 2003 started doing peer research. Staff and /or volunteers with lived experience of homelessness in every research project • In 2010 – our research found that health was often the missing piece in the puzzle of homelessness • HHPA was born! HEALTH

4. Resources for health – these and many more on our website

5. Training Healthcare Cards

6. Homeless Health Peer Advocacy (HHPA) • Supports people experiencing homelessness to address physical and mental health issues. We work to improve people’s confidence in using health services and increase their ability to access healthcare independently. • Our Peer Advocates have all experienced homelessness themselves. They go through a rigorous selection procedure (including DBS checks), attend a comprehensive training programme, and receive support and supervision to enable them to carry out the role safely.

7. Homeless Health Peer Advocacy (HHPA) Mental Health HHPA Working with people to support and address the mental health issues that are present and, in some cases, having a detrimental effect on people’s physical health. Groundswell Peer Advocates assist people with getting support from the secondary services such as the Community Mental Health Teams, Social Services and therapy based services. We also support those clients who have been given a dual diagnosis, which can cause them to be pushed between mental health and drug and alcohol services with neither wanting to offer a service.

8. Homeless Health Peer Advocacy (HHPA) In-reach Group sessions in day centres and hostels where different topics of health are discussed. A space to offer health related information, support and a chance for us to link service users with health professionals. Also a space for tea, cake and a chat. ICN – Integrated Care Network A partnership between Groundswell, Great Chapel Street and Dr Hickeys with a caseload of 30 people with complex health issues and 4 respite beds to prevent worsening health for rough sleepers and a period of intensive health support to prevent A&E attendance, hospital admission or further hospital admissions. Referrals made through clinicians at GCS and DHS

9. Homeless Health Peer Advocacy (HHPA) Camden Care Navigator – Based at CHIP Working closely with CHIP, local hostels, Day Centres and the Outreach Team to identify individuals with health needs who are not accessing services and supports them to access appropriate healthcare. City Care Navigator Care navigator embedded with the outreach teams in the City supporting rough sleepers to engage with health services.

10. Homeless Health Peer Advocacy (HHPA) Hep C Groundswell’s Peer Caseworker works with the Find and Treat University College London Hospital team to identify and screen patients for Hepatitis C. With the support of our peer advocates they visit homeless hostels and day centres to raise awareness of Hepatitis C and its risk factors, and encourage more people to be screened for the virus. Hospital Discharge Lambeth  Working with inpatients at Guys, Kings and St Thomas’ in order to support them to attend follow up appointments once discharged. Includes ward rounds and building relationships with people while in hospital. Also working collaboratively with the Three Boroughs (HIT) Nursing Team

11. Homeless Health Peer Advocacy (HHPA) • 2720 appointments in 2018-2019 • 68% reduction in missed outpatient appointments (Young Foundation, 2015) • Did not attend (DNA) rates for scheduled outpatient appointments fell from 34% to 15% (nearly) in line with general population (12%) (Ibid) • 42% reduction in unplanned care activity More importantly…..“If it weren’t for you guys coming and taking the time out and getting myself sorted out, I reckon I would have been dead now. That’s how much it made an impact in my life.” – HHPA Client “It’s quite empowering, I feel like a specialist elite force.” – Peer Advocate

12. Physical health - 78% have current problem and for 44% this was a long term condition 47% 37% 37% 29% 24% 24% “90% of participants had an issue with their mouth health since becoming homeless” (Groundswell, 2017) “Almost a third (28%) of people experiencing chronic pain reported obtaining opioids without a prescription in order to try and manage the pain themselves.” (Groundswell, 2017)

13. Mental health - 86% report as having a mental health problem and only 44% were diagnosed  34% 13% 7% Nine times more likely to commit suicide than the general population (Crisis, 2011) Over half of all deaths of homeless people in 2017 were due to drug poisoning, liver disease or suicide; drug poisoning alone made up 32% of the total. (ONS)

14. End of Life Case Study: John and Peter “I was supporting Peter for approximately seven months on and off with his cancer treatment and then palliative care.”​ One to One support – Same advocate, with a chance to build a trusting and supportive relationship ​

15. “We had to go ‘behind-the-scenes’ to make his wishes happen as the pathway that most people would follow would be into a hospice. Luckily he had a good manager at the hostel and me to fight for what he wanted.” Advocating on behalf of the individual with several different agencies “He did not want to go into a hospice. He wanted to die in the hostel to be around people that he knew”. Patient Choice - Dying in familiar surroundings with familiar faces/friends/carers

16. “The hospital staff and nurses were really helpful. That’s not always the way, sometimes staff look at you and see that you are going through addiction and you’re your own worst enemy and think ‘why should I care for you, why should I bother’. If there are ten people in the ward and one of them had caused a lot of the issues by himself, who should I help first?”  Stigma for the patient even towards the end of his life. He had addiction problems therefore he is partly to blame for his impending death. Perhaps leaving him vulnerable to less compassionate care?

17. “On his last trip to the hospital it was to accident and emergency and the nurses explained to him that he only had around five days to live and all he wanted to do was go back to the hostel and be with people that he knew. It was nice to see that he got his wish, even though the Macmillan nurses had to come to him in the hostel”.  -Caring organisations prepared to coordinate and be flexible in their approach

18. "He did get everything he required by going back to the hostel and having the end of life care nurse and a care plan put in place. A few days before he died we took him to Madame Tussaud’s for a day out to take his mind off it. Even though it was a struggle with his mobility, Peter loved it." -Providing some company and dignity in the last days of Peter’s life

19. “I understand that the pressures the hostel had to go through to support the client and maybe if he was in larger hostel you would have had our palliative care department but it was about understanding the client’s needs and facilitating them. “ -Fortunately, the hostel managed to find a separate bed space away from the main hostel which offered a more peaceful environment “I know that sometimes hostels don’t want to deal with cancer, things are a downward spiral and staff are affected by that and the see the residents get affected by that too. Because obviously someone close to them is dying. But Peter, If you put him in a hospice he would not have been happy he would have died miserable” -A death in a hostel can be traumatic for everyone, residents and staff alike

20. Good Practice – Specialist Services and resources • Specialist GP's – Dr Hickeys, Great Chapel Street, Health E1, Greenhouse • Pathways teams – St. Thomas, Guys, Kings, Royal London, UCLH • Outreach Nurses – Westminster, West London, Lambeth, Southwark • Integrated Care Network – Care Navigation and Respite Beds • Find and Treat (UCL) • Pharmacist for homelessness (Scotland) - offer a full health and medicines check, treat or refer • Gloria House – Step down beds – Royal London Hospital

21. Good Practice - Homelessness and Health Coordination • Homelessness and Health Coordinator Roles - Westminster and H&F • Health Action Groups in H&F and Westminster • A&E Frequent Attenders Meetings • Homelessness and Health MDT’s based in hospitals • Enhanced Vulnerability Forum - Westminster

22. Observations/Questions • Are appropriate levels of support in place for hostel staff and residents in relation to end of life issues? • Are some high support needs hostels with ‘older’ populations simply care homes with a lack of medical input and oversight?  • How many hostels have separate facilities for people in need of end of life care and Is there a need for a specialist hospice? • Given low life expectancy figures should homelessness be reframed as primarily a health issue and what impact would reframing have on existing services?

23. Thank You