Specialist Homelessness Services Research Articles

89 The Neuropsychology of Complex Homelessness

Objective:Although the cognitive profiles of people experiencing homelessness have been described in the literature, the neuropsychological profile of people experiencing complex homelessness has not been delineated. Complex homelessness is homelessness that continues despite the provision of bricks and mortar solutions. People experiencing complex homelessness often have an array of physical health, mental health, substance use, neurodevelopmental and neurocognitive disorders. The present study aimed to delineate the neuropsychological profile of people experiencing complex homelessness and explore the utility of neuropsychological assessment in supporting this population.Participants and Methods:19 people experiencing complex homelessness in Sydney, Australia, were consecutively referred by specialist homelessness services for neuropsychological assessment. They underwent comprehensive assessment of intelligence, memory and executive functioning and completed questionnaires to screen for the presence of ADHD, PTSD, depression, anxiety and stress. A range of performance validity measures were included. Referrers were asked to complete questionnaires on history of childhood trauma, psychological functioning, drug and alcohol use, functional cognitive abilities, homelessness factors, personality, risk of cognitive impairment and adaptive functioning and to note existing or suspected mental health, neurodevelopmental and neurocognitive disorders. Referrers also completed a post-assessment pathways questionnaires to identify whether the neuropsychological assessment facilitated referral pathways (e.g., for government housing or financial assistance). Clinicians completed a post-assessment diagnosis survey, which was compared to the pre-assessment known or suspected diagnoses. Finally, referrers were asked to complete a satisfaction questionnaire regarding the neuropsychological assessment.Results:Mean (SD) WAIS-IV indexes were VCI = 81.1 (14.5), PRI = 86.1 (10.9), WMI = 80.5 (13.0), PSI = 81.6 (10.2). Mean WMS-IV Flexible (LMVR) indexes were AMI = 68.3 (19.6), VMI = 77.1 (19.3), IMI = 72.7 (17.2), and DMI = 70.5 (17.6). The majority of participants showed unusual differences between WAIS-IV and TOPF-predicted WAIS-IV scores and between WAIS-IV General Ability and WMS-IV Flexible (LMVR) scores. Demographically corrected scores on tests of executive functioning were mostly one or more standard deviations below the mean. The majority of participants screened positive on screening measures of executive dysfunction, PTSD and ADHD and had elevated self-reported psychological distress scores. At least one new diagnosis was made for nine (47%) participants, established diagnoses were confirmed for two (11%) participants, diagnoses were supported for 15 (79%) participants, tentative diagnoses were made for 16 (84%) participants, and five (26%) participants had at least one diagnosis disconfirmed/unsupported. Referrers indicated that the majority of post-assessment pathways were more accessible following the neuropsychological assessment and that they were very satisfied with the neuropsychological assessments overall.Conclusions:This is one of the first studies to delineate the neuropsychological profile of people experiencing complex homelessness using robust psychometric approaches, including performance validity tests. This population experiences a high burden of cognitive impairment and associated substance use, neurodevelopmental and mental health comorbidities. Neuropsychological assessment makes referral pathways more accessible and is valued by referrers of people experiencing complex homelessness.

Excess Hospital Burden Among Young People in Contact With Homelessness Services in South Australia: A Prospective Linked Data Study

PurposeYouth homelessness remains an ongoing public health issue worldwide. We aimed to describe the burden of emergency department (ED) presentations and hospitalizations among a South Australian population of young people in contact with specialist homelessness services (SHS). MethodsThis whole-of-population study used de-identified, linked administrative data from the Better Evidence Better Outcomes Linked Data (BEBOLD) platform on all individuals born between 1996 and 1998 (N = 57,509). The Homelessness2Home data collection was used to identify 2,269 young people in contact with SHS at ages 16–17 years. We followed these 57,509 individuals to age 18–19 years and compared ED presentations and hospital separations related to mental health, self-harm, drug and alcohol, injury, oral health, respiratory conditions, diabetes, pregnancy, and potentially preventable hospitalizations between those in contact and not in contact with SHS. ResultsFour percent of young people had contact with SHS at ages 16–17 years. Young people who had contact with SHS were 2 and 3 times more likely to have presented to an ED and hospital respectively, compared to those who did not contact SHS. This accounted for 13% of all ED presentations and 16% of all hospitalizations in this age group. Excess burden causes included mental health, self-harm, drug and alcohol, diabetes, and pregnancy. On average, young people in contact with SHS experienced an increased length of stay in ED (+0.6 hours) and hospital (+0.7 days) per presentation, and were more likely to not wait for treatment in ED and to self-discharge from hospital. DiscussionThe 4% of young people who contacted SHS at ages 16–17 years accounted for 13% and 16% of all ED presentations and hospitalizations respectively at age 18–19 years. Prioritizing access to stable housing and primary health-care services for adolescents in contact with SHS in Australia could improve health outcomes and reduce health-care costs.

An analysis of the intersecting factors and needs that informed the experiences of young people transitioning from out of home care in the Australian states of Victoria and Western Australia

Young people transitioning from out-of-home care (often called care leavers) are globally a disadvantaged group who can be particularly vulnerable to experiences of housing instability and homelessness. This qualitative study, based on interviews with 34 care leavers in the Australian states of Victoria and Western Australia, examined their transition experiences and outcomes with a specific focus on access to stable and affordable housing. Our study reported major deficits in transition planning including a significant reliance when leaving care on specialist homelessness services to meet housing needs. Some major policy and practice reforms were identified concerning transition planning, service coordination, and extending the leaving care age to 25 years.

Heterogeneity among Homeless Australian Women and Their Reasons for Homelessness Entry.

Many women become homeless each year, both women who are alone and women with children. Both groups face substantial risks to their physical and mental health, as do the children of homeless mothers. Little is known about the similarities and differences between these two groups in terms of their demographic characteristics, their circumstances on presentation to specialist homelessness services, and the factors that have contributed to their homelessness. The current study analysed data from 163 single mothers with children and 126 lone women who presented to a specialist homelessness service in Australia. It found some similarities between groups, but also considerable heterogeneity. Single mothers were more likely to be younger, to have been born overseas, and to have been homeless in the past 12 months. Lone women were more likely to have medical issues, a mental health condition, addiction issues, admission to a psychiatric ward in the past 12 months, and to not be in the labour force. Implications for service delivery are discussed.

918Building the evidence base for australia’s veteran population

Abstract Background There is a wealth of existing research on Australia’s veteran population. However, much of the existing research seeks to answer questions on specific issues, veterans of specific conflicts, or of veterans who use the Department of Veterans’ Affairs services, with little to no information beyond these specific populations. Methods Several large administrative datasets including the Pharmaceutical Benefits Schedule (PBS), Causes of Death and Specialist Homelessness Services were linked with Defence information to enable analysis of veterans’ information against a range of topics, such as cause of death, health service and homelessness service use. Comparisons were made between the Australian Population as a whole and the veteran population. Results Results show some similarities and some differences between the veteran population and the whole Australian population. Results are disaggregated between those who are currently serving, in the reserves and ex-serving as well as by service type and other variables. Conclusions These results have helped to improve what is known about the broader veteran community. They provide important context for policy makers to understand how best to service the veteran community that was previously unknown, and help identify areas for more detailed research and exploration. Key messages Data linkage provides an important opportunity to understand the specific health and welfare needs of veterans who are otherwise difficult to identify in large administrative datasets. Comparison of veterans’ health and welfare service use with the broader Australian population provides important information for policy makers.

Promoting cervical screening among women experiencing homelessness and socio-economic disadvantage in Sydney.

Australia's national cervical screening program has reduced rates of cervical cancer morbidity and mortality. However, these benefits have not been experienced by all women. A Cervical Cancer Screening Project was implemented with lay health educators to address inequitable screening access by women experiencing socio-economic disadvantage. Resources and a training program were developed and piloted with the specialist homelessness services workforce in Sydney, NSW. Data was collected to inform their development and evaluation through interviews, focus groups, self-administered surveys and analysis of NSW Pap Test Register data. Women reported low familiarity with the term 'cervical screening'. They identified a good patient-doctor relationship, and seeing a female practitioner, as screening enablers. While the majority reported having cervical screening before, NSW Pap Test Register data showed only 74% had screened previously and of those, 69% were overdue. Homelessness service workers expressed interest in talking with clients about cervical screening, and reported increased knowledge and confidence following training. The homelessness sector is an appropriate venue to access women who are disadvantaged and under-screened. However, increasing workforce capacity to discuss screening does not lead to increased screening for women accessing these services. Further efforts are required. SO WHAT?: Access to cervical screening by women experiencing disadvantage remains a challenge. Sustained multi-faceted health promotion efforts are required to increase access. These should be informed by additional research exploring barriers and enablers for this group of women.

Inquiry into funding and delivery of programs to reduce homelessness

Inquiry into funding and delivery of programs to reduce homelessness

Consumer participation at Specialist Homelessness Services: Do the homeless have a say in the services they receive?

This study in the state of New South Wales, Australia, explored what Specialist Homelessness Services are currently implementing in regard to consumer participation, what is working and what barriers to consumer participation have been encountered by both service users and providers. Three staff members, one consumer volunteer and 10 homeless persons from three services were interviewed. The interviews were analysed using thematic analysis. The study found that while consumers have some opportunities to participate, and that participation is beneficial, there were barriers to participation, such as staff attitudes and the nature of the consumer group. The implications of these findings for staff, consumers and future policy direction are discussed.

Safe and sound? How funding mix affects homelessness support for Indigenous Australians

© Australian Housing and Urban Research Institute Limited 2016. The impact of mixed funding sources on homelessness support for Indigenous Australians forms one part of the research program in the AHURI Inquiry into the funding of homelessness services in Australia, which aims to understand the mix of government and non-government funding and how the funding of services that support people who are experiencing homelessness influences service provision and outcomes for those people. Indigenous Australians are 14 times more likely to become homeless than other Australians, and their homelessness situations are likely to be more severe. This research examines the extent to which the needs of homeless and at-risk Indigenous Australians are being met. The research used relevant findings from the AHURI Australian homelessness funding and delivery survey (Flatau, Zaretzky et al. 2016) plus five case-studies and three focus groups. Twenty-seven organisations with Indigenous Australians as a main client group participated in the survey. Findings in this research show that financial support to organisations that provide services to Indigenous Australians experiencing homelessness is primarily provided by governments through the National Partnership Agreement on Homelessness (NPAH) which funds Specialist Homelessness Services (SHS), with 94 per cent of funds from governments and the next largest source of funds (only 2%) from rent revenue. No federal or state program specifically targets supporting homeless Indigenous people or those at risk of experiencing homelessness. Services for homeless Indigenous people are overwhelmingly 'mainstreamed', with SHS funds going to Indigenous organisations but no targeted support or coordination with programs which are targeted at Indigenous Australians. Funding uncertainty is a major issue, and the problems (including operational inefficiency, inability of organisations to innovate, and impacts on staff recruitment and retention) caused by this precarity are notably similar, regardless of the location or type of service, with larger organisations best placed to cope. Homeless Indigenous Australians may not be receiving the kinds of support which are best suited to them, and current support may not be culturally appropriate. More than half of the survey respondents anticipate that negative consequences such as excessive reporting would result from attempting to further diversify their funding sources, including seeking funds from non-NAHA/NPAH sources.

The financing, delivery and effectiveness of programs to reduce homelessness

This research examined the funding sources of homeless services through administering a survey to Specialist Homelessness Services (SHS) and other (non-specialist) services which deliver homelessness services (non-SHS). While the survey highlighted that funding is predominantly from government sources, there is growing interest in the diversification of funding sources to meet service demand, enable service innovation and attain agency sustainability. Flexibility and discretion of funding utilisation is favoured by agencies to meet service objectives. Summary of key findings: Of the 398 Specialist Homelessness Services (SHS) (response rate 35.5%) that completed the survey – 298 of these provided organisational funding information (298 SHS represent approximately 20% of the services in the AIHW data collection) – while 216 provided funding dollar amounts. Also a small sample of 21 non-SHS provided funding information (with 17 providing funding dollar amounts). As this sample is likely to be unrepresentative, any findings in relation to these providers should be treated with caution and not directly compared to the SHS findings. Services profile – of the SHS and non-SHS respondent services (n=319) 17.7% of respondent services were homelessness specific agencies with 70.7% providing a mix of homelessness and non-homelessness services. Annual revenue of these services comprised: 21.9% less than $1m, 30.2% $1m–$5m and 47.9% greater than $5m. Funding profile (n=216 SHS that provided funding dollar amounts) – not surprisingly, 84.6% of funding received by SHS comes from government (49.5% via NAHA or NPAH). A further 5.2% government and 2.7% non-government funding is allocated by the parent agency. Only 3.6% of funding came from donations, philanthropy and sponsorships. Rent contributed to 92% of internally generated revenue. However this makes up only 2.4% of the total (internal plus external) funding source. For non-SHS (n=17) 60.6% of total funding came from government and 21.3% from donations/sponsorship/philanthropy. 75.6% of internally generated revenue came from social enterprise however this was only 0.7% of total funding. No SHS or non-SHS reported funding via social impact investors or social impact bonds. The level of unmet demand in the SHS sector suggests that resources are not adequate to meet demand. In 2013–14 for every 100 clients there were 60 unassisted requests and in 2014–15 there were 47 unassisted requests.

Is something better than nothing? Food insecurity and eating patterns of young people experiencing homelessness

Objective:Food insecurity is an increasing problem in marginalised groups that affects diet quality. We aimed to examine the extent of food insecurity and the eating patterns of young people accessing support from specialist homelessness services. Methods:A cross‐sectional survey with a researcher‐administered food frequency and food insecurity questionnaire was undertaken with 50 young people experiencing homelessness, aged 14–26 years. Participants were recruited from 11 specialist homelessness services providing support and accommodation for young people in central and south‐western Sydney. Results:Food insecurity was a recent experience for 70% of participants. Eighty‐five per cent of participants living independently experienced food insecurity, compared to 66% of young people in supported accommodation. Consumption of core food groups was low, as almost all participants did not meet recommended daily servings of vegetables and breads and cereals. Consumption of sugar‐sweetened soft drinks was high. Conclusions:Food insecurity and poor diet quality are salient issues for this group of young people accessing support from specialist homelessness services. Implications:These findings highlight the need for a greater focus on advocacy and policy action to increase social supports and improve food security and nutrition for young people experiencing homelessness.

Meeting national information needs on homelessness: Partnerships in developing, collecting and reporting homelessness services statistics

In 2008 the Council of Australian Governments agreed to national reforms to address homelessness through the Na- tional Agreement on Affordable Housing (NAHA) and National Partnership Agreement on Homelessness (NPAH). Integral to meeting the information needs to support these reforms was the development of a Specialist Homelessness Services data collec- tion. Working in collaboration with Commonwealth and state and territory governments, NGO service providers, peak homeless- ness bodies and a private sector information systems supplier, the Australian Institute of Health and Wealth (AIHW) developed a new national data collection and introduced an innovative data collection instrument and client information management system, known as SHIP. SHIP enables NGO case workers to easily capture client information, case manage clients and monitor their progress. SHIP allows seamless collection of data conforming to national data standards and submission to AIHW each month via a secure website. This paper describes the strong partnership arrangements that successfully delivered the new information system and data col- lection to 1500 NGO service providers across Australia and is providing valuable information to support measurement of policy effectiveness under the NAHA and NPAH in achieving successful outcomes for the clients of homelessness services.

Sustaining dignity? food insecurity in homeless young people in urban Australia.

Food insecurity is recognised as an increasing problem in disadvantaged and marginalised groups. The aim of this study was to investigate issues associated with food insecurity and nutrition in young people experiencing, or at risk of, homelessness in metropolitan Australia. Eight focus group discussions were conducted with 48 young people (aged between 15 and 25 years) in specialist homelessness services in central and south-western Sydney. Participants described daily experiences of food insecurity, persistent hunger and poverty. Structural barriers to food security and nutrition were identified and included poverty and reduced physical access to fresh foods. Participants also described a desire to save time, for convenience and to be socially connected. Despite the hardships and the chaos of youth homelessness, the groups were defined by their strength of character, resilience and hope for the future. Homeless young people within central and south-western Sydney report varying degrees of food insecurity, despite being supported by specialist youth homelessness services. SO WHAT? A collaborative, multistrategic approach with youth participation is required to further enhance the capacity of youth services to improve food security, food access and the availability of nutritious foods for homeless young people. A greater focus on advocacy and policy action is also required to bring food security and nutrition to the forefront of national efforts to improve the health and welfare of disadvantaged groups.

Housing Instability among People Who Inject Drugs: Results from the Australian Needle and Syringe Program Survey

High rates of substance dependence are consistently documented among homeless people, and are associated with a broad range of negative outcomes among this population. Investigations of homelessness among drug users are less readily available. This study examined the prevalence and correlates of housing instability among clients of needle syringe programs (NSPs) via the Australian NSP Survey, annual cross-sectional seroprevalence studies among NSP attendees. Following self-completion of a brief, anonymous survey and provision of a capillary blood sample by 2,396 NSP clients, multivariate logistic regressions identified the variables independently associated with housing instability. Nineteen percent of ANSPS participants reported current unstable housing, with primary ('sleeping rough'; 5%), secondary (staying with friends/relatives or in specialist homelessness services; 8%), and tertiary (residential arrangements involving neither secure lease nor private facilities; 6%) homelessness all evident. Extensive histories of housing instability were apparent among the sample: 66% reported at least one period of sleeping rough, while 77% had shifted between friends/relatives (73%) and/or resided in crisis accommodation (52%). Participants with a history of homelessness had cycled in and out of homelessness over an average of 10years; and one third reported first being homeless before age 15. Compared to their stably housed counterparts, unstably housed participants were younger, more likely to be male, of Indigenous Australian descent, and to report previous incarceration; they also reported higher rates of key risk behaviors including public injecting and receptive sharing of injecting equipment. The high prevalence of both historical and current housing instability among this group, particularly when considered in the light of other research documenting the many adverse outcomes associated with this particular form of disadvantage, highlights the need for increased supply of secure, affordable public housing in locations removed from established drug markets and serviced by health, social, and welfare support agencies.