Evaluating the perceived added value of a threefold intervention to improve palliative care for persons experiencing homelessness: a mixed-method study among social service and palliative care professionals.

BACKGROUND: Palliative care for persons experiencing homelessness who reside in social service facilities is often late or lacking. A threefold intervention was implemented to improve palliative care for this population by increasing knowledge and collaboration between social service and palliative care professionals. This consultation service comprised: 1) consultations between social service professionals and palliative care professionals; 2) multidisciplinary meetings involving these professionals; and 3) training of these professionals. This study aims to evaluate the perceived added value of this threefold consultation service in three regions in the Netherlands. METHODS: A mixed-methods evaluation study using structured questionnaires for consultants, requesting consultants, and attendees of multidisciplinary meetings, semi-structured group and individual interviews with social service and palliative care professionals involved, weekly diaries filled out by consultants, and an implementation diary. Qualitative data were analyzed following the principles of thematic analysis. Quantitative data were analyzed descriptively. RESULTS: Thirty-four consultations, 22 multidisciplinary meetings and 9 training sessions were studied during the implementation period of 21 months. Social service professionals made up the majority of all professionals reached by the intervention. In all regions the intervention was perceived to have added value for collaboration and networks of social service and palliative care professionals (connecting disciplines reciprocally and strengthening collaborations), the competences of especially social service professionals involved (competency in palliative care provision, feeling emotionally supported in complex situations), and the quality and timing of palliative care (more focus on quality of life and dying, advance care planning and looking ahead, and greater awareness of death and palliative care). CONCLUSIONS: The threefold consultation service particularly helps social service professionals connect with palliative care professionals. It helps them to identify palliative care needs in good time and to provide qualitatively better palliative care to persons experiencing homelessness.

[Homeless patients in Rotterdam with a need for medical care: data from the Rotterdam Street Doctors' office in the years 2006-2017]. / Rotterdamse daklozen met een zorgvraag.

OBJECTIVE: To describe the demographic and medical characteristics and changes of the patients who visit the Rotterdam Street Doctors' office hours. DESIGN: Retrospective study of registered patient contacts from 2006-2017. METHOD: Street doctors registered age, gender and ICPC diagnoses of patients in a GP information system. The characteristics of these patients have been analysed for three periods of four years: 2006-2009, 2010-2013, 2014-2017. For each of these periods, the number of individual patients visiting the Rotterdam Street Doctors' office hours at least once, have been documented. Data from the period 2014-2017, have been used to describe characteristics of homeless patients and have been compared with a regular GP practice. RESULTS: At the street doctors' office, patients with mental problems are most often documented, followed by patients with heart diseases and endocrine problems. Serious illnesses that require extra care are registered , such as drug and alcohol addiction, HIV, tuberculosis and hepatitis C. Patients with mental problems and trauma have a larger share at the street doctor's office than in a regular GP practice. The proportion of women has increased since 2006 as has the proportion of elderly patients. The proportion of patients with documented needs for cardiovascular diseases (in particular hypertension), endocrine disorders (in particular diabetes and thyroid diseases) and cancer has increased. CONCLUSION: A relatively large part of the patient contacts at the street doctor's office is devoted to mental problems and trauma. As the proportion of patients with chronic diseases and risk factors is rising, street doctor care seems to move towards regular care. But extra care for serious classical illnesses among the homeless is still necessary.

End-of-life care for homeless people in shelter-based nursing care settings: A retrospective record study.

BACKGROUND: Homeless people experience multiple health problems and early mortality. In the Netherlands, they can get shelter-based end-of-life care, but shelters are predominantly focused on temporary accommodation and recovery. AIM: To examine the characteristics of homeless people who reside at the end-of-life in shelter-based nursing care settings and the challenges in the end-of-life care provided to them. DESIGN: A retrospective record study using both quantitative and qualitative analysis methods. SETTING/PARTICIPANTS: Two Dutch shelter-based nursing care settings. We included 61 homeless patients who died between 2009 and 2016. RESULTS: Most patients had somatic (98%), psychiatric (84%) and addiction problems (90%). For 75% of the patients, the end of life was recognised and documented; this occurred 0-1253 days before death. For 26%, a palliative care team was consulted in the year before death. In the three months before death, 45% had at least three transitions, mainly to hospitals. Sixty-five percent of the patients died in the shelter, 27% in a hospital and 3% in a hospice. A quarter of all patients were known to have died alone. Documented care difficulties concerned continuity of care, social and environmental safety, patient-professional communication and medical-pharmacological alleviation of suffering. CONCLUSIONS: End-of-life care for homeless persons residing in shelter-based nursing care settings is characterised and challenged by comorbidities, uncertain prognoses, complicated social circumstances and many transitions to other settings. Multilevel end-of-life care improvements, including increased interdisciplinary collaboration, are needed to reduce transitions and suffering of this vulnerable population at the end of life.

[A homeless, uninsured illegal alien suffering from psychosis and multiple fractures: providing efficient care to such patients]. / Een dakloze, onverzekerde illegaal met multipele fracturen en een psychose: Hoe kun je zo'n patiënt doelmatige zorg verlenen?

We present the case of a 37-year-old psychotic, homeless man from Albania, who sustained multiple fractures after jumping from a third-floor window. The patient was uninsured and did not consent to transfer to a hospital in Albania because of paranoid delusions. Eventually he was hospitalised for nearly 30 weeks in hospital and a nursing home. Various factors of this complex case are considered, such as the co-morbidity of somatic and psychiatric symptoms, the absence of family support and the financial regulations that apply to uninsured patients. Doctors who are presented with similar complex cases are advised to organise frequent multidisciplinary evaluations with all health care workers involved. We encourage searching for creative interventions which serve both the best interests of the individual patient, and - where possible - also minimize the total cost of health care to society.

[Street doctors warn of epidemic of uninsured homeless persons in the Netherlands]. / Straatdokters slaan alarm over epidemie van onverzekerde daklozen.

Over the past few years, the Netherlands Street Doctors Group, a national network of doctors and nurses providing outreach primary care to homeless people in the Netherlands, has observed a growing number of homeless patients who do not have health insurance resulting in their access to healthcare services and medication being limited. In this article we raise the alarm about the epidemic of uninsured Dutch homeless. We explain and comment on the reasons why people are no longer insured and elaborate on the regulations and obligations related to homelessness and the characteristics of consumers and providers of social and medical services. We describe how difficult it is for homeless people to become re-insured as in order to follow a complex set of requirements commitment and patience are necessary. For most homeless patients, the re-insurance process requires the personal guidance and support of a motivated case manager. Consequently, we suggest that policy makers and service providers should have a better understanding of factors contributing to being uninsured and more compassion for those who are.

Pathways into homelessness: recently homeless adults problems and service use before and after becoming homeless in Amsterdam.

BACKGROUND: To improve homelessness prevention practice, we met with recently homeless adults, to explore their pathways into homelessness, problems and service use, before and after becoming homeless. METHODS: Recently homeless adults (last housing lost up to two years ago and legally staying in the Netherlands) were sampled in the streets, day centres and overnight shelters in Amsterdam. In April and May 2004, students conducted interviews and collected data on demographics, self reported pathways into homelessness, social and medical problems, and service use, before and after becoming homeless. RESULTS: among 120 recently homeless adults, (male 88%, Dutch 50%, average age 38 years, mean duration of homelessness 23 weeks), the main reported pathways into homelessness were evictions 38%, relationship problems 35%, prison 6% and other reasons 22%. Compared to the relationship group, the eviction group was slightly older (average age 39.6 versus 35.5 years; p = 0.08), belonged more often to a migrant group (p = 0.025), and reported more living single (p < 0,001), more financial debts (p = 0.009), more alcohol problems (p = 0.048) and more contacts with debt control services (p = 0.009). The relationship group reported more domestic conflicts (p < 0.001) and tended to report more drug (cocaine) problems. Before homelessness, in the total group, contacts with any social service were 38% and with any medical service 27%. Despite these contacts they did not keep their house. During homelessness only contacts with social work and benefit agencies increased, contacts with medical services remained low. CONCLUSION: the recently homeless fit the overall profile of the homeless population in Amsterdam: single (Dutch) men, around 40 years, with a mix of financial debts, addiction, mental and/or physical health problems. Contacts with services were fragmented and did not prevent homelessness. For homelessness prevention, systematic and outreach social medical care before and during homelessness should be provided.