16. FURTHER READING - ISSUES AND TRENDS
Access Health: providing primary health care to vulnerable and marginalised populations - a practice paper
Dr James Rowe (PhD), RMIT Centre for Applied Social Research, 2005.
This article was published in the Australian Journal of Primary Health (AJPH), Volume 11, No. 2, 2005 (La Trobe University). Copyright Australian Journal of Primary Health, reproduced with permission.
Following an extensive process, spanning nearly two years, the Salvation Army Crisis Services was funded to establish and operate a primary health service in St Kilda in accordance with guidelines set out by the Victorian Department of Human Services. On 1 September 2004,
was officially opened in a large building adjacent to Crisis Services and the primary NSP. In this paper, we seek to provide an insight into the initial establishment phase of a primary care facility designed to meet the health needs of a particularly vulnerable population. It outlines early trends in client need and the service response developed to meet these needs. It also touches upon the relationships that service management has pursued, the structure of the service, and the processes that have been put in place to address (the relatively few) teething problems that have arisen in the facility's first months of operation. In doing so, it provides insight of relevance to all practitioners who encounter the issues that marginalised and vulnerable clients with complex needs often bring.
Street-based IDUs experience many of the same health conditions as the general population. However they are at a disadvantage in respect of frequency, severity, and co-morbidity given the obvious impact on an individual's health of problematic drug use and the environment in which it occurs (e.g. Rowe 2003; Maher & Dixon 1999). The lack of financial security and the absence of secure housing mean that street-based IDUs suffer disproportionately high rates of chronically poor health (Babidge 1999; Darnton-Hill & Ash 1998; Hodder et al. 1998). Further, without some sense of stability and support to counter these factors, there are limits to improvements in an individual's health.
Despite high levels of need, mainstream health services often fail to provide care that is appropriate for street-based IDUs. The combined need to make (and keep) an appointment, for a Medicare card and/or money, and the reality of prolonged waiting times, is an obstacle to vulnerable clients, particularly those who are transient or in need of immediate care (Rowe 2003). Often health is not considered a priority in a chaotic life where survival takes precedence. Indeed, preventative health care and management of chronic illness is often overlooked (McDonald 2002).
Consequently, there is a need for services to be equipped to respond at
moment help is sought. If they are not, then relatively minor ailments may deteriorate to a point at which emergency treatment is required (McDonald 2002). Additionally, the health response that many mainstream services provide may be inflexible and, thus, inappropriate in the context of a client's complex, multiple and interconnected needs (Penrose-Hall et al. 2000). Discrimination, judgmental attitudes and lack of understanding (perceived or otherwise) only further contribute to limited contact with the mainstream health system (Abouyanni et al. 2000; Butt 1992).
practice innovation: 'Access Health' and the pursuit of partnerships
Outlining the factors that obstruct the access of street-based IDUs to mainstream health services was, while lengthy, a relatively uncomplicated research task (see Rowe 2004). Developing a service response to address the same obstacles has proven far more challenging. Access Health is open five days a week, conforming to conventional 9-5 business hours. [???] However, this is the only extent to which the service could be described as conventional. The services offered by Access Health are cost free and, largely, non-appointment based. [???]At the outset, the service was established with the aim to provide accessible and responsive primary health care to address the needs of:
- vulnerable/street-based injecting drug users;
- street sex workers; and
- people experiencing homelessness.
The nature of Access Health's clientele informs the delivery of primary health care within a social health framework, an approach to promoting health that acts to reduce inequalities and injustices. The complexity of health issues compounded by drug use, homelessness and transience demands a multifaceted, expert response. Recognising that the most effective means of offering such a response is through partnerships, Access Health collaborates with a range of existing health and support services to ensure appropriate primary care can be provided at Access Health while facilitating linkages with mainstream services. Partnerships with other agencies are based on either a co-location or fee for service capacity. At the beginning of March 2005, services offered on-site at Access Health and, where relevant, those organisations that they are employed by, include:
- community health nurses (7 days per week), RDNS Homeless Persons Program;
- duty workers (5 days);
- general practitioners (4 sessions), St Vincent's Hospital Department of Community Medicine;
- drug & alcohol counsellors (3 sessions), Inner South Community Health Service;
- psychologists / general counsellors (2 days), Melbourne Counselling Service;
- indigenous access worker (1 day per week);
- health promotion worker (4 days);
- drug safety worker (1 session);
- sexual assault counsellors (1 session), South Eastern Centre Against Sexual Assault (SECASA);
- psychiatrist (1 session), Bayside Health / Alfred Hospital Community Psychiatry; and
- researcher/evaluator (2.5 days per week), RMIT Centre for Applied Social Research.
The development of partnerships has facilitated the referral and progression of clients between different elements of the service system while ensuring access to immediate (and opportunistic) care in one location. A more 'seamless' service system means a reduced degree of navigation is expected of clients for whom engagement with just one facility may prove challenging. Further, entering into partnerships has greatly simplified processes such as case conferencing, shared care, secondary consults and has provided for enhanced joint case management and planning with particularly complex clients.
At the time that they seek to engage with the service, the majority of clients at Access Health initially request intervention for a physical health issue. Consequently, their first contact with the service's practitioners is often with the service nurses who, in addition to providing clinical care, record the 'issues' with which clients present. In the January-March quarter, community health nurses had 817 client contacts. Clients, however, may present with more than one issue. As a result, the number of presenting issues recorded far exceeds the number of client visits. The percentages listed below refer to the proportion of the 817 client contacts that community health nurses reported: [???]
||(76.5% of client contacts)
It is to be expected that the most reported reason for contact with nursing staff would be related to physical health problems. Interestingly, more than half of client contacts with nurses were for drug-related reasons. The range of presenting issues recorded by nursing staff demonstrates how it is often during the course of the initial consultations at Access Health, that concerns around drug and alcohol use, mental health and social issues are identified. This is when the benefits of service provision based on co-located partnerships are most apparent. While community health nurses nursing staff (and GPs) offer an immediate primary health response to a number of clients who possibly wouldn't otherwise access care, their assessment skills enable them to make referrals to co-located (and external) specialists.
It is important to emphasise that the development of these partnerships did not take place without sufficient work and effort. Before the establishment of the service, several issues had to be considered to ensure the co-located services were able to work together effectively. These included having:
- a compatible philosophy;
- a shared commitment to the target group;
- a shared understanding of health and homelessness;
- a sense of shared endeavour and ownership; and
- clarity and collaboration regarding issues such as:
- referral / shared care processes;
- communication between workers / client confidentiality; and
- service delivery models.
The first three issues are interrelated. Obviously, partnerships would have soon collapsed had not the respective partners shared a commitment to a social health framework and an ability to work with highly stigmatised populations in an accepting, non-judgmental manner. Typically, the main limitations associated with service partnerships arise as a consequence of a lack of clarity around the roles and responsibilities (of both the host and co-located agencies). Referral protocols, client confidentiality and financial costs may also present issues. At Access Health, for example, co-located staff are not expected to fulfil administrative functions such as duty work. Nonetheless, it is expected that differing duty of care issues between various disciplines will occur in the context of shared care practices. To minimise any disruption or difficulties that may accompany such issues, all Access Health partnerships have been built around formalised contracts that encompass:
- the aim and target group of Access Health;
- the nature of the position;
- lines of accountability, responsibility and communication;
- financial agreements;
- grievance procedures;
- termination, variation and disputes;
- joint planning and evaluation;
- client records (including privacy/confidentiality issues); and
- access to resources at the site of operation.
Additionally, a number of communication strategies have been implemented. These include team meetings, shared case notes (in some cases), case presentations and clinical review meetings. These measures enhance clinicians' understanding of their colleagues practices (particularly those of colleagues from other disciplines) and result in collaborative and improved health care for clients. Obviously, there is a need to ensure that the strategies for addressing potential difficulties are identified prior to partnerships becoming operational. Time invested prior to their commencement may well save a much greater amount of time at a later date.
the first nine months - practical lessons for practitioners
In the initial months of operation, many homeless and street-based individuals were attracted to Access Health by the availability of food and coffee making facilities. Access to showers (and the free provision of basic toiletries including soap, shampoo and shaving equipment) also attracted those with limited access to the facilities needed to maintain personal hygiene. Many clients initially came into the service purely to use these services. Continued contact with duty workers ultimately led to engagement and the development of a relationship with the service. This stresses the importance of duty workers who are non-judgmental and possess the skills required to engage and manage complex clients with often challenging behaviours. A number of the more vulnerable clients, initially attracted by the 'drop-in' component of Access Health, have been made to feel sufficiently at ease by duty workers to access the facility's clinical staff. Recruitment of ably equipped 'front of house' staff cannot be overstated when seeking to engage marginalised clients in need of health care.
After nearly six months of operation, the decision was made, in early February, to restrict access to food/coffee making facilities. This decision was taken for a number of reasons. Over the six months, regular clients had been made to feel welcome to a new service and the reticence of particularly marginalised individuals had been overcome through a gradual process of engagement. However, and perhaps more importantly, Access Health risked losing it's focus as a health service and becoming known as a 'drop-in' centre. Further, the issue of prioritising resources was identified. The greater the amount of money spent on food ultimately means less money is available for the provision of material aid such as pharmacy vouchers.
At the same time, Access Health staff acknowledge that (poor) nutrition and hygiene are two of the most pressing health issues they confront. Showers remain available to all clients on a drop in basis. Similarly, food is available. However, it is distributed on the basis of nutritional need as assessed by clinical staff and not as an emergency relief response. Further, a drop in lunch is available to all clients one day a week as a continued means of engagement. Fresh fruit and drinking fountains are provided in the waiting room. Certainly, the decision to restrict access to food was a difficult one. But there are valuable lessons to be learnt regarding service identity and the prioritisation of resources. Further, the number of clients registered at the service continued to grow following this decision, suggesting that it has not affected attendance.
In January 2005, the clinical management software program Pracsoft was installed. In addition to clinical information, Pracsoft records the age and gender of clients 'registered' at Access Health. Registration is not a 'condition' for using the services available at Access Health. Some clients may be reluctant to disclose personal information for a variety of reasons and, consequently, remain unregistered. They may access the service in an informal capacity (e.g. to use showers and toilets). However, clients must be registered when a clinical intervention occurs. In this first month of its operation, 183 clients were registered on Pracsoft. By the end of February, 305 clients were registered and at the end of the first quarter of 2005, there were 383 clients on the Pracsoft database. The breakdown of the age and gender of clients is provided in Table 1 below.
Table 1: Demographics by age and gender (January-March 2005)
Female: 37.6% Male: 62.4%
Men have consistently comprised the greater proportion of Access Health clients, accounting for slightly more than 60% of those using the service. This has led to some gender-based issues.
Indeed, despite extensive research and feasibility studies and the lengthy negotiations that preceded the opening of Access Health, it would have been naÃƒÂ¯ve to expect the facility to operate without encountering some teething problems. Any service dealing with complex issues and vulnerable clients must be structured in a way that allows modification of practice as issues arise. One such issue has been perceived male 'ownership' of common client-based areas (e.g. the waiting room (equipped with television and chairs)) and the front yard area (with tables and chairs). Many of Access Health's female clients have had negative, and often violent, relationships with men. A proportion are street sex workers who have experienced significant gender related power abuses in both their private and public domains. Consequently, some women may be understandably reluctant to wait in an area in which men appear to dominate. A number of women have noted the intimidating nature of common areas:
The drop in group [for lunch on Wednesdays] started to be a bit like that. I thought, as soon as something good starts it's like all these guys come and push in, everyone is going to get a meal but they'll just push in, like, you've got to wait in line. Some of them are okay and some of them are no good (Female, aged 31). [???]
This has become less of an issue since unlimited food and coffee was discontinued. Initially, many older, homeless, alcoholic affected men would use the facility for respite from the streets. Many of these men now attend Sacred Heart Mission a short walk down Grey Street where coffee, breakfast and a drop in space is offered. Staff have also sought to address concerns regarding the weekly drop-in session. The presence of two skilled, female staff ensures a better gender balance, a feeling of security for vulnerable women and an informal monitoring situation, with the capacity for intervention when needed. Furthermore, in the months of April and May, the number of female clients has increased at a faster rate than male clients, suggesting the women are comfortable with the structure and service model offered at Access Health.
The ability to survey and address such issues as they arise is important. For this reason, Access Health incorporates an evaluation component, in the form of an on-site researcher, to monitor the facility's operation during its developmental stages. The evaluator/researcher assists staff by identifying areas in which delivery of services may be improved or modified. This is done by gathering information about client outcomes and client satisfaction with the services offered by Access Health through interviews (with clients and staff), surveys and collation of electronic data. In addition to providing for the continued assessment of the efficacy of the service model, this allows data to be provided to funding bodies at regular intervals. Both of these outcomes will contribute to the long-term sustainability of Access Health as a primary health facility.
Finally, it is essential to note the challenges and rewards (to both the Salvation Army Crisis services and Access Health ) of establishing a health service within a welfare agency. Both parties have needed, and worked, to gain a thorough understanding of the philosophies and models with in which the other functions. This is one of the few occasions where the two sectors are not functioning in silos but are (becoming) integrated and enriched. Most importantly, however, those who most benefit are the clients who have access to increased service capacity as a result of the expansion of the 'one-stop-shop concept'. [???]
Access Health has only been operational for nine months and unexpected issues may still arise. However, the feasibility studies and research process that preceded this operation has doubtless minimised these to a considerable degree. This and the willingness (and ability) to respond to further issues as they arise are two of the most important aspects that allow the service to function to the degree that client numbers continue to grow. Perhaps more important are the principles according to which the service functions. Namely, that all people are entitled to quality, responsive health care that meets their unique and, at times multifaceted needs. For marginalised individuals and populations, (such as street-based IDUs, street sex workers and people experiencing homelessness), these needs include, not least, a lower health status than other members of the community. Recognition of this fact and the concurrent building of primary health care partnerships has enabled Access Health to go some way to addressing these needs while winning the respect of clients who, to many in the health and welfare sector, are seen as too challenging to deal with:
NoteI guess it's like any business in its infantile stages. It's going to have to go through teething and working out what's going to work and what's not but stuff from the general community is that it's coming together great. That's the vibe I get. Everyone is happy with it and I talk to so many street people, you wouldn't believe it (Female, aged 44).
I would like to acknowledge Ms Sue White the manager of
for comments and assistance in the drafting of this report and the staff and clients of
for their cooperation. Acknowledgement should also go to the Salvation Army Crisis Services for pursuing the best service possible in the interests of their clientele. Finally, I would like to thank the two referees for their constructive criticisms.
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