Over 55 & Homeless

Over 55 & Homeless

AMA (NSW) recently contributed to the NSW Parliamentary inquiry into homelessness amongst people aged over 55 in New South Wales. COVID-19 has exacerbated many of the factors that contribute to homelessness, which is turn is leading to increased rates of homelessness in NSW and putting additional strain on services. Women in this demographic are particularly vulnerable.

The factors that increase the risk of an individual becoming homeless have intensified during the pandemic. The impact of COVID-19 on people’s mental and physical health combined with a significant lack of affordable housing and an increase in domestic violence, has created a ‘perfect storm’ for those at risk of homelessness.

There are increasing numbers of people aged over 55 experiencing homelessness. The Australian Institute of Health and Welfare found the number of older people experiencing homelessness was double the annual growth rate of the Specialist Homelessness Services (SHS). 

People at most risk of homelessness include women, Indigenous Australians, individuals in a single person household or single-parent household, those on low income or unemployed, and people receiving income support payments.

Older women are now the fastest growing cohort to experience homelessness in Australia, with a 31% increase in homelessness among older women between 2011 and 2016.

Women over the age of 55 are at greater risk of financial hardship and housing insecurity due to systemic factors, including lack of superannuation, the gender pay gap, age discrimination in the job market, part time employment status, and employment history gaps due to childbearing and raising a family. Life events such as the death of a spouse, illness and divorce can trigger homelessness for this vulnerable group. This demographic is the fastest growing group of homeless people in Australia. Research published in 2020 found 240,000 women aged 55 or older and another 165,000 women aged 45-54 are at risk of homelessness.

It is clear from the evidence that homelessness has a significant impact on an individual’s health.

Being homeless can exacerbate an already existing condition or put an individual at risk of developing a new condition, including poor oral health, chronic disease, skin and foot problems, infectious diseases such as tuberculosis, hepatitis C and HIV infection, substance abuse, and mental illness.

People experiencing homelessness present frequently to hospitals which places a significant burden on the public health system. 

While hospitals are able to deal with acute health issues, it is expensive care that does not address the other factors that can contribute to homelessness. 

Furthermore, it is a preventable cost to the health system that could be avoided if barriers to healthcare access for people experiencing homelessness were to be improved.

Research has found services that specialise in providing patients with a medical service that can manage complex multi-morbidities, mental illness and drug and alcohol issues, as well as trauma-informed care can be particularly effective. 

Combining these medical services with case managers who can help people secure social housing, or support for NDIS packages is an important part of that service. These specialised services address some of the personal and relationship barriers previously examined that can prevent individuals from accessing traditional health sector service models. 

There are many examples of specialised services that have a track record of success in assisting patients experiencing homelessness. 

These services have been effective at providing assistance to people who are most vulnerable in the community; however, there is a need to ensure funding is sufficient to meet the growing need in communities.

While specialised services have proven to be effective at providing healthcare access to people experiencing homelessness, there is additional need to adequately support general practice. 

General practitioners are often the first port of call when people experience physical and/or mental ill health. As a result, GPs are well positioned to provide early intervention to patients who are at risk of homelessness. 

Aligning health and social care via general practice

Addressing homelessness is part of healthcare. As outlined in the paper from Stanford and Wood: “Addressing homelessness is, itself, an important form of healthcare, not a separate ‘non-health’ issue.”

For those experiencing homelessness, or at risk of homelessness, a general practice is a safe place and if it is also a place where there is consistency of practitioner and practice health staff. This allows for better outcomes and care that is comprehensive. 

Medicare and block funding to support general practice in provision of care

In addition to experiencing a physical or mental health condition, people at risk of homelessness who present to general practice may also be experiencing a drug and alcohol problem, mental ill health, trauma, and/or family violence as well as housing instability. They may also experience lower levels of literacy and therefore require support in filling in forms for Government financial assistance and housing assistance.

Solving these complex conditions is time consuming and requires a team-based approach to healthcare. Remunerating practice health staff to assist with health assessments for patients at risk or, or experiencing homelessness, would allow for tailored care that encompasses the patient’s whole-of-health needs. 

The criteria for health assessment item numbers currently does not cover homelessness as a reason for initiating a health assessment. Health assessments allow practice nurses to be engaged as part of the MBS rules. Creating a health assessment item number that could be used be utilised by the general practice team, including but not limited to practice nurses, would give general practices greater flexibility in providing care to this cohort.

The criteria for health assessment item numbers currently does not cover homelessness as a reason for initiating a health assessment. Health assessments allow practice nurses to be engaged as part of the MBS rules. Creating a health assessment item number that could be used be utilised by the general practice team, including but not limited to practice nurses, would give general practices greater flexibility in providing care to this cohort. 

Alternatively, we recommend funding practices to provide enhanced services through block funding which can be applied to the practice team as appropriate (eg. For phone outreach, emails, texts).

Building capacity and capability in general practice

Coordinating social and health services from mainstream general practice can be challenging. Equipping general practitioners with the tools and education to better meet the needs of these complex patients will increase the system’s capacity to assist people experiencing homelessness.

The continued use and expansion of HealthPathways is valuable in supporting this capacity building. This is valuable resource for GP teams that are less familiar with, or have less exposure to, assisting people experiencing homelessness. 

Access to specialised drug and alcohol advice also gives greater confidence to general practitioners who feel under-equipped to deal with the complexity of issues that people experiencing homelessness can present with. 

In addition to ensuring referrals services are easily accessible, there is a need to adequately resource these services so that they are more responsive.

Models for provision of complex care

There currently exists models where GPs can refer families with complex care needs for assistance by linking to appropriate services. The Western Sydney Kids Early Years (KEYS) Network is a new approach that aligns health and social goals and is designed to deliver cohesive, coordinated services. It relies on multi-sector collaboration. While KEYS was developed to assist children aged five and under and their families, the model could be adapted to serve patients experiencing homelessness.

A second model that currently exists is the Neighbourhood Health Hub, which links patients to many of the same services but for a broader cohort. These service structures serve as vehicles to achieve an objective rather than being service providers in their own right, but all start from the fundamental premise that patients should be linked with a usual practice.

More generally, Government could improve access to general practice by addressing some of the financial and practical barriers currently exist. 

Bulk Billing

People who are at risk of homelessness are typically financially disadvantaged and unable to access medical services that are not bulk billed.

The MBS rebate has not kept pace with the costs of providing services. As a result, many practices have been forced to adopt a private billing model resulting in out-of-pocket costs for patients. The Productivity Commission’s Report on Government Services 2022, shows in 2020–21 just 67.6% of patients had all GP services bulk billed.

Recent figures found the bulk billing rate is down 1.2% in the December quarter of 2021 from the previous quarter (89.6%). Further to that, the average patient contribution per GP service peaked in Q3 of 2020–21, at $42.79.

The Commonwealth Government must close the gap between the indexation of Medicare schedule fees and the indices for CPI, average weekly earnings, and the AMA fees.

Workforce

Australia’s GP shortage also contributes to reduced access to healthcare services. Fewer doctors-in-training are choosing general practice as a specialty. Applications for GP training dropped by 22% between 2015 and 2020. Meanwhile, unfilled rural training places increased from 10% (65 places) in 2018 to 30% (201 places) in 2020. Almost 40% of the GP workforce is over 55. As older general practitioners retire over the next five years the situation is expected to worsen. A lack of available medical services has put pressure on appointment availability. A two to three week wait for an appointment is not uncommon, particularly in rural and regional areas. Government action to improve the appeal of a career in general practice is needed, including adjustments to remuneration for registrars and improvements in entitlements. Policies to accelerate recruitment into areas of need, particularly rural and regional NSW must also be implemented.