Primary care street services vital in filling health gaps for marginalised patients

It would surprise few to learn that people experiencing homelessness often have a difficult time connecting with many of the services most of us take for granted – financial, occupational, and many others.
 
Healthcare, unsurprisingly, is also on that list.
 
‘People who are homeless or marginalised have poor engagement with mainstream healthcare services. They often feel disconnected from society and the broader community, and feel more comfortable in a “waiting room” with others facing similar life circumstances,’ Diane Arnold-Reed, Associate Professor in the General Practice and Primary Healthcare Research Unit at the University of Notre Dame Australia, told newsGP.
 
‘Street health services fulfil an important role in providing a general practice service for such marginalised patients that focuses on their psycho-social and medical needs.’
 
Associate Professor Arnold-Reed is the lead author on a recent study tracking multimorbidity prevalence using medical records from patients of the Freo Street Doctor, a mobile street-based primary healthcare service based in Fremantle, WA. ‘Increasing multimorbidity in an Australian street health service: A 10-year retrospective cohort study’ highlights the importance of such services in filling the gaps for disadvantaged patients who are uncomfortable with mainstream services.
 
As growing numbers of Australians experience homelessness, it is important to measure the scale of chronic disease and multimorbidity among these more marginalised patients in order to provide appropriate services – but such information can be difficult for researchers to access.
 
‘Patients from more disadvantaged or socioeconomically deprived populations tend to attend mainstream practices less, in a clear reflection of the inverse care law,’ Associate Professor Arnold-Reed said. ‘Thus there is little opportunity to unravel the combinations and severity of disease of this patient cohort at the primary care level.’
 
However, the Freo Street Doctor mobile medical health service offered an opportunity for Associate Professor Arnold-Reed and her team to investigate the prevalence of multimorbidity among this population, and provide a different point of view from prior studies in this area.
 
‘We felt it was important to identify all chronic diseases in these patients and not just the drug and alcohol related conditions,’ Associate Professor Arnold-Reed explained.
 
The study involved assessing patient records from the Freo Street Doctor service from between 2006–15. Over that time, researchers found half of all patients (53%) were experiencing multimorbidity. They also found its prevalence increased over time, with 63% of patients experiencing multimorbidity between 2012–15 compared to 46.4% between 2006–11.
 
‘Overall, most conditions were of mild-to-moderate severity, but approximately a third of patients had at least one severe or extremely severe condition,’ Associate Professor Arnold-Reed said.
 
The findings also yielded some surprising information about the homeless patient population.
 
‘Patients attending the street health service were relatively young, with an average age of 38 years, yet over half could be classified as having multimorbidity,’ Associate Professor Arnold-Reed said.
 
‘Also, just under 32% of attendees were Aboriginal, which is high compared to mainstream general practice, where Aboriginal attendance is less than 2%.’
 
Presentations of multimorbidity also differed significantly between Aboriginal and non-Indigenous patients as they aged.
 
‘The distribution of multimorbidity showed increases with age, peaking at 45–64 years and then flattening for non-Aboriginal patients 65 years and over, and less so for Aboriginal patients,’ Associate Professor Arnold-Reed said.
 
‘The reasons for this are unclear. It could be that older non-Aboriginal patients move off the streets due to reasons such as death or moving to sheltered housing or nursing homes, but that older, less healthy Aboriginal patients continue using the service.’
 
Associate Professor Arnold-Reed believes these results underscore how services such as the Freo Street Doctor fulfil a vital and increasing need in Australian healthcare.
 
‘Mainstream general practice offers good value for money and is inexpensive compared to hospital medicine,’ she said. ‘However, it is unlikely that homeless patients will increase their use of these services as they stand.
 
‘To provide greater equity in access, we need practices that recognise the special needs of such patients and don’t make them feel unwelcome.’
 
Access Associate Professor Diane Arnold-Reed’s paper in the April 2018 edition of AJGP for further information on assessing multimorbidity among patients of the Freo Street Doctor street service.

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