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June Shannon talks to Safetynet’s Dr Angela Skuce about the recently established Step Up and Step Down Intermediate Care Centre, which is providing a vital health service for homeless people
“They are all people who could be looked after at home, if they had a home.” This is how Dr Angela Skuce, Safetynet Primary Care GP describes her patient population at Ireland’s first Step Up Step Down (SUSD) Intermediate Care Centre for people who are homeless.
Opened in September 2018, the 12-bedded facility fills a void in homeless health services that has been an issue for decades, by providing medical and nursing care to homeless people who ‘step up’ from the community or ‘step down’ from an acute hospital bed.
The SUSD Intermediate Care Centre is a residential facility operated by Dublin Simon Community and Safetynet Primary Care, with support from Housing First, HSE ACCESS Mental Health, and the inclusion health teams at St James’s Hospital and the Mater Misericordiae University Hospital, Dublin.
The service is funded and supported by HSE Social Inclusion and the Department of Health.
The unit at Dublin Simon Community’s Usher’s Island Complex provides short-term semi-acute healthcare (medical and nursing) interventions, treatment, and investigations for people who are homeless. The patients treated in the unit are not sick enough to be in hospital, but need medical care or support and/or follow-on care following discharge from hospital.
The SUSD Intermediate Care Centre has admitted 92 people since opening last September and the number of referrals from hospitals, Safetynet clinics and other community-based services has been increasing as word spreads about the positive impact of the service. So far in 2019 there have been 64 admissions.
Approximately 20 per cent of those who are admitted to the unit are women and 72 per cent are men, reflecting the wider homeless population. The average age of patients is 45.
Dr Skuce is one of two GPs who provides medical care at the SUSD unit along with her colleague Dr Claire Dunne. The GPs who staff the unit are provided by Safetynet Primary Care.
Along with two GPs, the service is also staffed by a nurse manager, five nurses, a counsellor, a care assistant and a project worker.
According to Dr Skuce, the patient profile is a mixture of people who are long-term homeless for 15 years or more, and those who have recently become homeless in the last year.
“Probably about half of the people who come in have some sort of substance misuse issue, whether that be drug use or alcohol dependence and the other half don’t, but that drug and alcohol use wouldn’t be the main thing that brings them in, that would just be a complicating factor,” Dr Skuce told the Medical Independent.
She said that the more common conditions seen in the unit included chest infections and pneumonia. Patients are those who have just been discharged from hospital or those who are not sick enough to be admitted to an acute hospital, but are too sick to be in hostel accommodation. Patients who need IV antibiotics can also be cared for at the unit, freeing up an acute hospital bed.
“They come into us for the duration of their antibiotic treatment and just to be out of the rain, to be somewhere where they can take their tablets three or four times a day and where they can get fed,” Dr Skuce stated.
“Also, people who have been in hospital with bad pneumonia will sometimes come to us for a week afterwards to get back on their feet and build up their strength. One of the really important things that the project worker does is help them source better accommodation so while they are with us, we can often get them moved from one night only accommodation to longer term beds or at least to accommodation that they can access 24 hours a day.”
The Safetynet GP explained that the other common presentation she encounters at the SUSD unit are patients with poorly controlled type 2 diabetes caused by long-term alcohol abuse who were on insulin.
The chaotic nature of their lives means that homeless people on insulin find it difficult to control their diabetes. However, if they are admitted to the unit for a week or two, they can get the support they need, take their medication appropriately and have regular meals. This also gives their GP in the community the chance to properly monitor their condition and make any changes to their treatment if needed.
Patients are also admitted to the SUSD unit with a range of mobility problems including broken limbs, foot ulcers or abscesses. Without the unit these patients would be forced to leave their hostels at 8am in the morning and walk the streets all day in pain and discomfort.
“They just can’t walk around all day every day,” said Dr Skuce.
“Some of them come in just for a place to be looked after and fed while their broken ankle heals or to have their leg or foot ulcers dressed and cleaned regularly. We have huge success with leg ulcers. If you keep the leg up, keep pressure on it and keep the swelling down, then the ulcer will heal quickly, whereas if you are on your feet and walking around and not getting your dressings changed regularly, they can go on for years.”
The SUSD unit is also used for patients preparing for a procedure or minor operation. At the unit they can prepare for a procedure like a colonoscopy, for example, which would be extremely difficult if they were sleeping rough or in a hostel.
Patients who are discharged from an acute hospital to the SUSD unit include those with amputated limbs and cancer patients. People who are on chemotherapy can stay at the unit as it provides a safe space for them to recover in the immediate aftermath of a chemotherapy session.
Dr Skuce explained that the facility also cared for a small number of patients who are experiencing a mental health crisis.
“If they are not deemed ill enough to be in a psychiatric hospital, they can come to us as a place of safety and nurturing. Dublin Simon has a counselling service available seven days a week and a counsellor can come and visit them here in the unit. We don’t take people with acute psychosis, but people with less severe, but still very distressing mental health difficulties.”
The maximum length of stay at the SUSD is three weeks and Dr Skuce explained that the rule of thumb was, “whatever they have got, if we can help it get better in three weeks or less, then we can take them in. There is some flexibility around that, but we wouldn’t aim to keep people more than three weeks.”
Increase in referrals
The Dublin Simon SUSD unit has only been in operation for just over eight months and, in that time, Dr Skuce said they have seen an increase in the number of referrals particularly due to word of mouth.
The unit can accept referrals from any doctor working in any sector and from nurses working in the homeless service. Dr Skuce said that if anyone was uncertain as to whether to refer or not, they could simply pick up the phone and call the unit for advice.
Dr Skuce paid huge tribute to the network of dedicated staff working across the homeless services in Dublin, which she described as an invaluable resource to the SUSD unit. From the inclusion health teams in St James’s and the Mater Hospitals, to the Safetynet Primary Care service, Merchant’s Quay and the Capuchin Day Centre, this established network provides much needed support and information that helps the SUSD unit care for patients in a holistic manner.
“I was anxious starting it because I haven’t worked in hospital medicine for 20 years or more and I was worried that I might get people in that were too sick for us to be looking after, but we haven’t. They are all people who could be looked after at home if they had a home… if there is somebody who gets sick or that we need advice on, all the hospital staff have been really supportive to us, which is really helpful.”
Dr Skuce added that the patients themselves also appreciate the unit and the care they receive.
“They just love it and it’s heartbreaking to see. It is not a plush building, it is not a five-star hotel. It is fairly basic, but just for them to have somewhere to be and with staff who are seen as authority figures being nice to them and treating them appropriately. Having other people to chat to and not having to be outdoors every day killing time. They just value it so much.”
It has been more than a decade since the case for an intermediary care centre for the homeless in Ireland was first mooted in 2006 by the founder of Safetynet Primary Care and Dublin GP Dr Austin O’Carroll.
According to a report entitled Homeless Health and the case for an Intermediate Care Centre, by Austin O’Carroll, Fiona O’Reilly, Mary Corbett, and Liam Quinn, which was published in May 2006, “homeless people have higher mortality and morbidity yet have decreased access to primary healthcare services. An intermediate care centre could help address the health needs of homeless people in providing both a suitable alternative for homeless patients to be discharged to as well as a suitable facility to treat medical conditions that are too serious to be treated in hostel/B&B accommodation and yet are not serious enough to warrant hospital admission.”
The report also argues that cost savings can be achieved by intervening for these patients before they require hospital admission.
For Dr Skuce it is simple. In her opinion, not having an intermediary care centre for homeless people was “inhumane”.
“If somebody has a bad chest infection anybody else would go to bed and their mother or their partner or sister would bring them up chicken soup. Whereas people who are living in hostels are up and out at 8 o’clock in the morning and the best we can advise them is to go sit in the library in the Ilac centre and that is the best you can come up with, which is just inhumane. They are all doing the best they can, it is not that they couldn’t be bothered looking after themselves better. Given their circumstances and their skills and abilities they are doing the best they can and society just needs to add the bit that is missing.”