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'He chose to die at home. The hostel was his home' Lynn Ruane on hidden health problems in homelessness

The health rights of people in emergency accommodation are not a subject that comes up often enough, writes Lynn Ruane.

FOR YEARS I have observed minority groups experience poor health due to inequality.

Often people who experience homelessness are the least likely to receive adequate health care, even though in many cases they are the most likely to need it.

Take homeless older men for example. Many homeless men live with chronic illness. And when I say older I do not mean it in the same way I would if I was talking about the general population.

Often people who have spent years on the streets age far before their time. They are old by the time they reach their forties. Studies have shown life expectancy is not the same as the rest of the population.

There are hundreds of men currently living in hostel accommodation that require the equivalent to nursing home care or full-time carers.

Right now in Ireland many hostels de facto operate as nursing homes for the men we once knew as the “street drinkers”.

During my time in these service I have witnessed staff and medical practitioners work tirelessly to try meet the high needs of this vulnerable group.

With not enough services, support and expertise this has meant that on many occasion they have not been cared for in the way they should.

This is why the new intermediate care centre or ‘Step Up Step Down’ provided by the Dublin Simon Community with Safety Net Primary Care is crucial to meet that need.

‘To them that is home’

This new medical unit will look after sick homeless people or allow them to recover after being discharged from hospital. Though it won’t solve their housing problem it may help them survive homelessness.

I have watched men being discharged or self-discharging after major surgery to return to a homeless hostel.

We say hostel, but to them that is home and they want to return home.

In many cases withdrawals from alcohol or drugs feeds into their need to leave the hospital.

The new twelve bed unit will provide a step down from hospital or step up from the hostel environment and will play a vital role in delivering the health interventions that this group so desperately needs.

For this particular group we also need to think about palliative care. I remember a couple of years ago while working in a hostel, I sat with a dying man until he took his final breath.

He chose to die at ‘home’. The hostel was is home. For decades he knew no other home.

I was privileged to be able to respect his wishes and allow him the respect he deserved.

As we have an aging homeless population, the provision of palliative care to people without homes will continue to arise and I believe must be flexible and respectful in how we meet their health needs.

‘Call for Action’

A few weekends ago, I addressed the Irish Street Medicine Symposium hosted by Safetynet Primary Care at the Trinity’s Institute for Population Health in Tallaght. Over the course of Symposium the participants agreed on a “Call for Action”.

There are some very important and necessary recommendations in the document that they developed.

This includes improving care and protection for rough sleepers in extreme weather conditions. It also includes recommendations such as the establishment of a ‘task force’ responsible for devising and coordinating the response to protect the health of rough sleepers in extreme weather.

There was a recognition that not all rough sleepers will agree to go into emergency / hostel accommodation in extreme weather and, as a result, an alternative strategy to protect those who choose to stay on the streets in extreme weather needs to be developed and appropriately funded.

The specific needs of this cohort of people has to date been largely overlooked.

Another call was for the provision of high protein and high calorie meals and snacks for homeless people at risk (night shelter, rough sleepers) to prevent malnutrition.

Shockingly, malnutrition is estimated to be about 10 times higher among homeless people. The symposium rightly called for the development monitoring of nutritional standards for homeless services and direct provision centres.

While participants agreed that housing is the most effective way to protect the health of those without homes, they nevertheless agreed that emergency accommodation should be open 24 hours removing the need for people to wander the streets potentially further compromising health.

The number of people with poor mental health is much higher among the homeless and indeed homelessness can cause or increase mental health problems.

An expansion of supported accommodation with appropriately trained staff for people with severe and enduring mental illness was seen as a critical need now.

These are just some of what the doctors, social workers, service providers and service user called “no brainers’ in providing care for a very vulnerable group who need and should have a better quality of care provided to them.

These are discussions we should be having as policy makers, but unfortunately the health rights of people in hostel and emergency accommodation is not something that comes  very often, in my experience.

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