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'We don't discharge people to the streets': The hospital dilemma of how to discharge a homeless person

32 homeless patients were admitted to St James’s Hospital during each of the months of September, October and November.

HOMELESS PEOPLE ARE three to four times more likely to die prematurely than the general population – a gap that widens even further in winter.

That is according to Deutsches Arzteblatt, a German medical journal, which looked at how inclement weather and freezing temperatures puts homeless people in greater need of medical treatment than at any other time of the year.

To help counter the effects, more than 330 extra beds have been made available to homeless people in Ireland this winter as part of the Cold Weather Strategy announced by the Dublin Regional Homeless Executive (DRHE) earlier this month. 

Winter 2018 has seen 156 people sleeping rough in the Dublin area – a slight decrease from last year, according to Focus Ireland and the DRHE.

In attempt to aid homeless people in need of medical treatment and those that are admitted to hospitals, the HSE has started rolling out the National Hospital Discharge Protocol for Homelessness.

The Discharge Protocol is a guidance framework that “aims to ensure that clear procedures are in place (involving the Health Services, Local Authorities/Homeless Action Teams and the Voluntary Sector) so that all discharges of persons experiencing homelessness or at risk of homelessness from acute and mental health care services are planned, with the necessary accommodation and supports in place prior to discharge”.

First piloted in St James’s Hospital and the Mater Hospital in early 2017, the HSE said that the framework would be introduced throughout the year. However, with 2018 coming to a close, the protocol has yet be implemented in any other hospitals – nearly two years after it was piloted.

Dr Cliona Ní Cheallaigh is a consultant of general medicine and infectious diseases at St James’s Hospital. In 2016, she co-founded the Inclusion Health Service in the hospital – a service which supports those with acute and psychiatric medical needs but find themselves vulnerable or marginalised in society. 

“We’ve put a lot of work into it over the past couple of years to really try and recognise that homeless patients have very high needs and they need extra support both in terms of coming into the hospital and in terms of their discharges,” she says. 

Ní Cheallaigh says that there is a lot of education required regarding the needs of homeless patients and their aftercare.

There’s a lot of work that healthcare providers need to do and hopefully we are starting to do that now in terms of being aware of what it’s like being homeless and making our services friendly and accessible.

Part of this education is making sure that all homeless patients are discharged with a full medical and social assessment completed. They also might require physiotherapy, she says. 

“You might be OK going back to your house after you’ve had pneumonia but somebody who’s going to have to be out during the day carrying all their stuff, they would need to be a bit stronger, so there’s a lot of education needed. Hopefully now we’ve started on that,” she says. 

According to a St James’s Hospital spokesperson, on average, 32 homeless patients were admitted during each of the months of September, October and November. 

When contacted for similar figures regarding homeless admissions, the Mater Hospital did not supply comment. 

Anthony Flynn, co-founder of Inner City Helping Homeless and housing advocate says that “from our experience the framework hasn’t been [fully] rolled out, particularly in the Mater hospital, where people have been released back onto the streets frequently”.

Although Ní Cheallaigh says that the Mater Hospital also has had a liaison nurse for the past year, helping homeless patients in a similar capacity, Flynn says that the resources available to staff at the hospital are not adequate.

“We have experienced homeless people needing an ambulance having been discharged while not fully recovered from a surgery. A proper framework correctly implemented could prevent readmissions,” he says. 

It is not the front line staff that are the issue, it’s the fact that they are criminally under resourced.

A major aspect of the Discharge Protocol and the Inclusion Health Service is the commitment to make sure that all patients who face homelessness the day of discharge have a bed for the night. 

“The point is that we don’t discharge people to the streets – so they have to have a bed to go to for that night of discharge,” says Ní Cheallaigh. 

The struggle, however, is the lack of long-term accommodation for patients with the need for follow-up care. 

“It’s really tough and much of the time the bed that they are going to isn’t 24-hour access and it would only be for that one night,” she says.

“Leaving hospital tonight, they’d get a bed but tomorrow morning I don’t know where they’re going. That’s very difficult for the hospital to arrange follow up. We don’t know where we can send follow-up appointments, we don’t know where to send a public health nurse into, we can’t do the same sort of follow up compared to someone who goes back to their house.” 

Often, Ní Cheallaigh says, patients who would require specialised treatment or accommodation would find themselves in inappropriate spaces that could be detriment to their recovery. 

“Often we would have difficulty finding something for someone with higher needs. Maybe they need a zimmer frame or it’s almost impossible to get something that’s drug or alcohol free – you might have somebody who doesn’t use drugs or alcohol and you’re sending them into a place where heroin, other drugs and alcohol is prominent. So it’s really tough,” she says.

Flynn says that he has seen patients discharged into highly unsuitable situations, oftentimes causing the readmission of the patient. 

“Sending someone back into a hostel or to rough sleeping isn’t going to lead to a proper recovery,” he says. 

“The two biggest issues facing this country in 2018 are homelessness and the hospital crisis. The one common factor is the fact that both homeless services and hospitals are massively under resourced when it comes to bed availability. This can lead to people slipping through the cracks or being discharged before fully recovered,” he says.

Ní Cheallaigh says that healthcare providers have a duty to make the government aware of what is needed to help the homeless population.

“We can do our bit well but we also have to talk to other bits of system about what we see and what we can think can be done better,” she says.

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