Innovative co-design of integrated services designed to improve access to health care

摘要

An introduction: (comprising background and problem statement) Homeless people suffer higher mortality and morbidity rates than the general population at the same time their access to and indeed use of health services is less than the housed population. Description of policy context and objective : Ireland is currently experiencing an increase in homelessness. There is a shortage of suitable housing and this together with unaffordable rents in the private sector is pushing people out of their homes. There is an urgent need to: - focus services on homeless people and families in emergency accommodation; - accelerate the provision of social housing; - deliver more housing; - use vacant homes; and - improve the rental sector. These issues are addressed in Rebuilding Ireland: Action Plan for Housing and Homelessness (2016-2021). The HSE support the provision of specific health aspects of the plan. The HSE, together with the Local Authorities, has joint responsibility to provide a coordinated and integrated response to delivering homeless services to this growing group. The HSE Homeless Services oversee and manage a range of services and supports. These are provided through outreach specialist services, and specialised teams and individuals. They are contracted through the voluntary sector, to deliver services on behalf of the HSE to service users from diverse groups. Targeted population : Homeless population and others that the mainstream services don’t reach. Highlights : (innovation, Impact and outcomes) This innovative model of service policy planning and practice sees operations as an integrated system brought together by a common aim ; to provide access to services to vulnerable populations that mainstream services do not reach. The model operates within the policy and structural framework of the HSE’s National Drugs Rehabilitation Framework for health care provision. Within this framework Safetynet Primary Care (a medical charity) provides three levels of care i) Open access drop- in clinics for homeless people and others ineligible for mainstream services or unable to attend them. Typically these sites are appended to NGO non-medical low threshold services with high service user engagement (needle exchange, drop in food hall etc) ii) In-Reach Primary Care teams – at this level service provision takes medical care to the emergency hostels following best practice for health care for this cohort iii) An outreach service operates via mobile health unit targets the most vulnerable of the target group ie those without accommodation (rough sleepers) . Each level of service is provided by a mix of statutory non statutory and private organisations with Safetynet coordinating patient care via a web based patient management system ensuring that wherever patients are seen their medical records are available to the medical professional treating them. The integrated model however extends beyond the Primarycare domain to secondary care where a Social Inclusion team has been established in one of the cities Acute hospital. Co-ordination of patient care at the interface between primary and secondary care is managed through Multi disciplinary team working accross the two domains. An Innovative Partnership for Health Equity exists between researchers policy makers and planers and education has meant action research has been implemented to determine the homeless population’s health needs and service utilisation. This research has enabled policy , programme design to be finely attuned to need. This research has shown the increased development of services overtime of access to health care and access to key working and case management for the homeless population in Dublin Comments on transferability : This approach is adaptable to other urban centres in Ireland and Internationally. It also demonstrate that this level of interagency working is possible and can extend to other marginalised groups with complex needs suffering from inequalities such as refugees, travellers and migrants. Conclusions: (comprising key findings, discussion and lessons learned) The layered Safetynet system of provision for people falling through the service gaps for hard to reach groups is enhanced by Partnerships that demand reform in order to ensure health equity is reality rather than rhetoric .