Walk a Mile in Their Shoes
Matthew Christie, Access Team Outreach Podiatrist, North Yarra Community Health
Over the past two decades Australia has experienced an uninterrupted period of economic growth.1 It has also been suggested that ‘this growth has not been accompanied by signs of emerging economic imbalances.’2
Despite this, growing problems surrounding homelessness are prevalent. In 2011 the rate of homelessness in Australia rose eight per cent compared to the 2006 census. The number of people homeless in Australia in 2011 had also risen 17 per cent over the ﬁve years, a ﬁgure no doubt reﬂective of the growth in population.3 As the population continues to grow, current trends in homelessness are sure to continue.
People experiencing homelessness suffer from increased rates of chronic disease, death and disability and barriers exist that restrict their access to health care.4 Common health concerns are vast and include a range of podiatry issues.5
People experiencing homelessness often experience drug and alcohol dependence, complex mental health problems and day to day challenges relating to food insecurity, staying safe and ﬁnding temporary accommodation. The consequences of a transient lifestyle means that the standard models in place to provide health care services are not suitable. Therefore a re-orientation of traditional healthcare models is required, to enable an accessible, holistic, multidisciplinary and preventative range of services to be available to this cohort.6
North Yarra Community Health (NYCH) is based in the inner Melbourne suburbs of Collingwood, Carlton and Fitzroy. It provides a wide range of high quality, responsive care to some of Melbourne’s most disadvantaged groups. NYCH recognised that an improvement in service provision and access to health care for the homeless was needed. Home and Community Care (HACC) Flexible Service Response (FSR) funding supports the provision of services exclusively to people experiencing homelessness and those at risk of homelessness. This was followed by a reform internally at NYCH, which saw the creation of the Access Team over ten years ago.
The Access team provides HACC FSR funded services, which include physiotherapy, dietetics, occupational therapy, podiatry, casework counselling, nursing and Aboriginal support. Its target group are people who are homeless or at risk of becoming homeless.
The Access Team plan their programs and services under the following objectives:
- Ensure our services are accessible and responsive to the target group.
- Improve client participation in social, physical and cultural activities.
- To ensure that the target group is aware of our services.
- To foster collaborative working relationships with appropriate local organisations.
- Increase capacity for all NYCH staff to work effectively with our target group.
- To participate in improving quality of care and meet accountability requirements.
- To participate in health promotion and advocacy to inﬂuence the broader social determinants of health that inﬂuences our clients. 7
Since taking up the Access team podiatry role in August 2011, providing foot care services to the homeless has accounted for the majority of my work. Having trained in Britain under the National Health Scheme (NHS) I am used to being able to access information about a client prior to ﬁrst contact. On the rare occasion that a client would present without a comprehensive medical history and referral, information was almost always available on the county health care record database and failing this a quick phone call to the local GP provider was all that was required. Comparatively however, obtaining a thorough medical history for those who are transient is no mean feat.
Another notable difference to my previous work is the attitude and expectations of the clients
themselves. Under the NHS model (‘free health care from the cradle to the grave’) clients had an ingrained philosophy towards accessing services. Even in the event of non-compliance, people would continue to access services because it was their right to do so, meaning appointments are seldom missed and people always attempt to access health care.
Working within the Access team at NYCH, it wasn’t long before I realised my whole approach to providing ostensibly the same service as in the United Kingdom would have to change. I often found myself ﬁghting a losing battle when trying to instil the importance of attending appointments to my clients and the negative impact on health in not doing so. What became apparent was that for whatever reason, health care was not a priority and that working with them would require a change of mindset as a health professional. The resources I had available had to change to meet the client’s needs.
The majority of my HACC FSR funded work is provided in centre at our Fitzroy site via the Homeless Persons Drop in Clinic, and alternate Tuesdays at our Inner Space site for injecting drug users. The Homeless Drop in Clinic is a centre-based (Fitzroy) ﬂexible session each Monday between 9 am–12.30 pm. HACC FSR eligible clients may attend on the day for assessment or treatment without a prior appointment. This system works on a ﬁrst come, ﬁrst served basis. The clinic at our Inner Space site is an afternoon of scheduled half hour appointments where clients can either make an appointment or just ‘drop in’.
At ﬁrst, treating out of the Drop in Clinic felt more like a form of ‘band aiding practise’, than actual structured health care management. Intervention and equipment costs money and you are working with people on very limited, and over-stretched statutory incomes. Upon my arrival at NYCH the ‘Homeless Footwear Project’ supplied people experiencing homelessness with one free pair of shoes following a podiatry needs assessment. This program was however nonoperational due to lack of funding. Following some success in obtaining
a small grant to keep the homeless footwear project alive, I realised that this population were presenting with far more acute and chronic complaints than footwear alone could resolve. So I made an application for a considerably larger grant to the RE Ross Trust, my argument being that there should be no ﬁnancial restrictions to the provision of aids and equipment for people with acute and chronic complex foot conditions. It seemed a no-brainer that early intervention through provision of suitable footwear would avoid exponential costs in terms of pain, disability and acute hospital bed days.
The cost of an ED presentation without an acute admission is around $396. The comparative cost of an acute care episode following an admission through ED however is more in the region of $4092.8
Between 3.9 per cent and 10 per cent of annual ED presentations in Australia are by people experiencing homelessness, and the readmission rate of people experiencing homelessness compared to those in stable housing is approximately three fold.9, 10 A review of St Vincent’s hospital inpatient services also revealed that people experiencing homelessness accounted for 33 per cent of its acute admissions.11
Given these current trends in ED presentations it is not difﬁcult to see the potential long term positive impact of directing funding towards community health services that aim to improve accessibility and service provision for the homeless. The funding required for programmes such as the homeless footwear project is small compared to the potential savings in reducing ED presentations.
The incentive of a free pair of shoes has vastly increased the number of in centre client contacts, with many people experiencing homelessness self-referring over the past 12 months. During consultations, I am able to provide a full podiatry and general medical assessment, treat and provide aids and equipment without ﬁnancial restraint and in turn refer to additional services on a needs basis.
The provision of care has been further enhanced with the introduction of a GP drop in clinic, which runs concurrently with the allied health Homeless Drop in Clinic. Having rapid access to a GP has allowed for immediate antibiotic prescription, diagnosis and treatment of other complex medical conditions, within days of presentation to podiatry. This model provides an accessible, responsive, respectful, multidisciplinary, holistic, client centred approach.
In recent months the Homeless Footwear Project has been able to address some of the broader complex social issues associated with homelessness like mental health and well-being, increasing the opportunities for people experiencing homelessness to beneﬁt socially, physically, emotionally and mentally from being physically active.
- Allocations of runners to clients wishing to access the community gyms program run by NYCH physiotherapists
- Provision of brand new football boots to the Collingwood Knights, a local football team made up of people from a disadvantaged background.
The Homeless Footwear Project has also enabled group shoe shopping trips for the residents of the Common Ground project. Seeing the positive impact of people being able to shop for shoes without prejudice or ﬁnancial restriction was a humbling eye-opener for me, in realising how socially isolated and disadvantaged our client group really are.
The project has also allowed for the customisation of an electric bike for a client who is homeless and suffers with Parkinson’s Disease. Working closely with the NYCH Occupational Therapists and TADVIC, we have been able to preserve his independence and ability to be an active part of his community.
In spite of all its success stories over the past 12 months, programs like the homeless footwear project will only continue to be a success if funding streams are maintained. Successful community programmes therefore need to be made public knowledge, so community services can adopt
their principles and funding providers can see their importance.
After all: ‘Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control ’.12
- Economy watch, 2010, Australia Economy, Retrieved 10 February 2013 from http://www.economywatch.com/ world_economy/australia/?page=full
- Parkinson, M 2012, Australia’s place in the new global economy, Address to CEDA State of the Nation, retrieved 10 February 2013 from, http://www.treasury.gov.au/ PublicationsAndMedia/Speeches/2012/ Australias-place-in-the-new-global-economy
- Australian Bureau of Statistics, 2012, 2049.0, Census of Population and Housing: Estimating homelessness, 2011, retrieved 10 February 2013 from http://www.abs.gov.au/ ausstats/abs@.nsf/ latestProducts/2049.0Media per cent20Release12011
- Lynch, P 2005, Homelessness, Poverty and discrimination: Improving public health by realising human rights. 10 Deakin Law Review, 233, retrieved 9 February 2013 from http://www.deakin.edu.au/buslaw/ law/dlr/docs/vol10-iss1/vol10-1-11.pdf
- Swanborough, T 1999, A framework: improving health outcomes for people experiencing homelessness in Victoria, Royal District Nursing Service Homeless Persons Program, Melbourne
- Weiland T, and Moore G 2009, ‘Health services for the homeless: A need for ﬂexible, person-centred and multidisciplinary services that focus on engagement, InPsych, October, 3, 2009, retrieved 13 February from http://www.psychology.org.au/ inpsych/ health_homeless/
- Access Team Service model and team philosophy 2012
- Ministry of Health, 2011, ‘The 2009/10 NSW Costs of Care Standards are a guide to estimating the costs of health services’, retrieved 13 February from http://www0.health.nsw.gov.au/policies/ gl/2011/pdf/GL2011 007.pdf
- Moore, G, Gerdt, G, Manias, E, Hepworth, G, and Dent, A 2007, Socio-demographic and clinical characteristics of re-presentation to an Australian inner-city emergency department: implications for service delivery. BMC Public Health 2007, 7:320
- Department of Human Services, 2005, ‘Mental health presentations to the emergency department’, A Victorian government initiative. Retrieved 14 February 2013 from http://www.health.vic.gov.au/ mentalhealth/ emergency/mh-presentations.pdf
- Giles, L, Reynolds, F, O’Mahony, J, and McGeorge, P, 2006, ‘The Cost of Homelessness’, Power Point presentation, National Homelessness Conference, 2006
- The Universal Declaration of Human Rights1948, Article 25. Retrieved on 10 February 2013 from http://www.un.org/ en/documents/udhr/index.shtml#a25