The power of integration; a joined-up response to homelessness across hospital, primary care and community services  

Background: Homelessness is a global problem, and strongly linked to poorer health outcomes, higher rates of hospital use, and a sobering three-decade gap in life expectancy. While barriers to health care access contribute to this, the absence of safe stable housing is a fundamental driver of their poor health. The enormous health inequalities associated with homelessness are inextricably linked to the cumulative effect of social and structural disadvantages. To tackle these health and social disparities effectively, less siloed responses are needed. What have we been doing to address this? Over the last 8 years, a unique health-led collaboration in Perth Western Australia, has provided trauma informed healthcare and linkages to housing and social supports for over 10, 000 people experiencing homelessness. This collaboration is anchored around a large primary care practice (Homeless Healthcare), that sees people in wide range of community settings, including drop-in centres, crisis accommodation, and via street outreach. In collaboration with Perth’s major inner-city hospital, a dedicated Homeless Team was established; integrating hospital medical care and patient advocacy with daily primary care in-reach and the embedded involvement of case workers who connect clients to accommodation and psychosocial support. Strong partnerships have been forged within the homelessness, housing, and social care sectors, as this is crucial to addressing the ‘revolving hospital door’ associated with chronic homelessness. Having the same health and case worker staff work across multiple settings is an important part of the integrated model of care. Central to all of this is person-centred and trauma-informed care, with people who have experienced homelessness at the heart of how services are designed and delivered. This has expanded recently to include peer support workers with a lived experience of homelessness. Longitudinal evaluation data shows that the integrated impact on health and social outcomes is far greater than the “separate parts”, yielding tangible benefits not only to the patients supported, but also to the health system. Our evaluations have demonstrated substantial reductions in hospital use, and many health conditions are now better managed through far less costly primary care. That ‘housing is health’ is a fundamental ethos, and it is among patients connected to safe and secure housing and social supports that the greatest improvements in health are seen. The ultimate evidence of integrated care success is seen in the evaluation case studies and client feedback, many of whom have languished on the streets for years being bounced between disconnected homelessness, welfare and health services. Next steps include efforts to sure up sustainable funding for these services and collaborative work, and joint evidence led advocacy for new initiatives to address service gaps around dual diagnosis, homelessness and pregnancy, trauma therapy and to increase rapid housing pathways for people