Pharmacist Prescribers Working With People Who Are Homeless
NHS Greater Glasgow & Clyde
The health of people who are homeless is worsening, with the Accident and Emergency (A&E) visits, outpatient non-attendance and drug related deaths increasing. Health services are struggling to engage and meet the diverse needs of this marginalised group. People who are homeless have low rates of healthcare engagement, low uptake of preventative interventions including prescribing and increasing rates of presentation to emergency services.
Assertive outreach is an approach used to engage with those who are unserved or underserved by existing agencies, and who are not able or willing to seek services from those agencies. It involves relationship building, with the outreach service having an ideology of care e.g. social inclusion, and unconditional support, based on strong principles and values.
This project is a sibling project of the Edinburgh PHOENIx approach and introduces a Pharmacist independent prescriber (fully integrated with Homelessness Health Service) alongside Street Work team worker, to assertively outreach in Glasgow city centre and also running regular drop ins at the streetwork hub for health & social care.
- What was the approach?
A team comprised of a pharmacist and a Streetworker worked together every Monday, on outreach, visiting a range of venues and walking the streets in the city centre of Glasgow. They were embedded in the wider Pharmacy outreach team and the wider Simon Community Street team.
The pharmacist and Simon Community Streetworker visited low threshold homeless venues in the city centre. The service lead, having worked in many of the hostels and services, met the lead for each homeless venue/service, to introduce the PHOENIx team and asked when would be appropriate to visit. The team requirements were minimal – a room in the venue, and support from the venue/service staff to identify patients in advance. Induction and training was provided in house, with time spent shadowing other healthcare professionals, and the Simon Community Street team.
Health checks lasted approximately 30-40 minutes. Everyone was offered a health check, regardless of their circumstances. After a period of induction and acquisition of equipment including a laptop connected remotely to the Hunter St Homeless practice records and NHS GG&C wide clinical portal. Two levels of service were offered to reflect different types of needs. Both involved a health check: core (for all patients) and enhanced (for patients recently discharged from hospital). The main difference between core and enhanced service is in the persistent (weekly) follow up offered to patients in the enhanced service, until the patient/pharmacist feels they no longer wish weekly support.
- What was the impact?
Between 21st August 2017 and 21st August 2018 one hundred and forty five patients received a health check. The aim was to reduce the use of A&E presentations in a targeted group of patients.
For people who are homeless and have been involved in the Pharmacists’ work over the past three years, the offer of health engagement has been well received and accepted. This is likely due to the offer being made in the patient’s own environment, where there is freedom from hierarchy and long delays. The pharmacist had more time to spend with the patient than other healthcare professionals working at the front line with this group. Furthermore the involvement of a Simon Community Worker ensured housing, benefits and other forms of immediate need, were addressed at the same time. More time with patients led to improved trust between pharmacist, Simon Community worker and patient. The Pharmacists’ ability to assess, diagnose (limited to conditions within their competency) and prescribe on the spot, and follow up, led to improvements in diagnoses, treatments and onward referrals.
During the one year follow up period starting from the date of the first health check, the mean number of follow up consultations was 1.5 per person (SD 2.6) with 31 (86%) receiving between one and four follow up consultations and five (14%) receiving five or more.
There was general health follow up such as spirometry and offered monitoring for this from the Streetwork hub and GP. People were supported to access accommodation and offered social prescribing. Over a three month period in the drop in at the hub ( 1.5 hours/week), 3-4 people per session seen dealing with issues and the range from acute illness from physical and mental health issues, substitution treatment, monitoring of respiratory conditions and blood borne viruses as well as onward registration referral at GP/ dentist/physio.
- What was the learning?
- There are challenges to continuity of care when patient disappears.
- Healthcare response to people who cannot or will not manage to attend designated primary care centre.
- Housing and health are inextricably linked and needed to be considered at the same time.
- What are the next steps?
There is ongoing funding for both the pharmacist and the street worker and continue to develop the outreach on the streets, hostels and drop in at street work.