Three novel models of outreach, integrated health services for vulnerable populations

INTRODUCTION Persons experiencing social disadvantage including homelessness, substance use and mental illness experience poor health outcomes, high rates of untreated chronic diseases and shorter life expectancy. Many are not linked to mainstream primary health care and cannot prioritise their health over daily survival needs. Consequently, health seeking is often delayed, resulting in high rates of late-stage presentation to Emergency Departments and more serious illness. In many instances these outcomes may have been prevented through proactive and timely primary care intervention. With funding from St Vincent’s Health Australia’s (SVHA) Inclusive Health Program, St Vincent’s Hospital Melbourne (SVHM) is piloting three novel, integrated models taking care outside traditional hospital walls, to places where disadvantaged persons congregate. AIMS These models broadly aim to: -Establish partnerships with key community agencies to establish integrated and proactive health responses -To engage with hard-to-reach consumers attending these community services -To improve the health outcomes of these vulnerable consumers -To reduce preventable, acute hospitalisations as a result of unmet health needs METHOD Models 1 and 2 are two years into their three-year pilot term and Model 3 is a two year pilot which commenced in 2019. Model 1 is a Primary Health Hub at the Salvation Army (SA) 614 Precinct in Melbourne’s CBD. The SA provide meals and practical supports, whilst working with clients to create pathways out of marginalization. SVHM has embedded a 1.0FTE Registered Nurse and a 0.5FTE Mental Health Clinician on-site to engage with consumers, assess/treat acute health needs (e.g. wounds, infections), address chronic health needs and link people into appropriate primary or tertiary health services. Model 2 is a partnership between SVHM, Jesuit Social Services (JSS), Bolton Clarke and The University of Melbourne, embedding a 0.8FTE Registered Nurse within JSS’s ReConnect prison release case management team. The nurse provides outreach 1:1 clinical care and secondary consultation/capacity building with ReConnect’s 18 case managers. Model 3 is a partnership between SVHM and North Richmond Community Health’s Medically Supervised Injecting Room, embedding an Infectious Diseases Nurse and Mental Health Clinician to engage with consumers to address their complex physical health, mental health, substance issues and psychosocial needs. RESULTS Early results from all three projects have seen high rates of consumer engagement with the health professionals. The projects are being quantitatively and qualitatively evaluated by way of cohort demographics, identified health needs, service delivery provided, consumer outcomes and healthcare utilisation. Case studies are providing rich information about entwined, complex health and psychosocial needs that are validating the need for these flexible, outreach service models. Key learnings include the need for dedicated partnership planning to ensure well-aligned project implementation, appropriate clinical governance and support for staff working in these outreach environments and thorough evaluation frameworks to assess project effectiveness. DISCUSSION Across health, housing and welfare sectors there is increasing recognition of the need for integrated health and welfare service responses. SVHA is providing significant financial investment to pilot these models with comprehensive evaluation frameworks to contribute to best practice evidence to support sustainable funding.