Guidance developed by the Queen’s Nursing Institute advises nurses how they can assess the health of homeless patients and ensure they receive the care they need
New guidance on assessing the health of homeless people features an assessment template for community nurses working with this group. It includes key questions on general physical health, mental health, long-term conditions, substance use, sexual health and housing. It also incorporates template care plans for use by both nurses and patients, and includes Read Codes for practice-based settings. This article looks at the impact homelessness can have on health, and summarises the Queen’s Nursing Institute’s guidance on assessing the healthcare needs of homeless people.
Citation: Parker-Radford D (2015) Assessing the health of homeless people. Nursing Times; 111: 51/52, 14-15.
Author: David Parker-Radford is homeless health project manager, The Queen’s Nursing Institute.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here
Homelessness can have a critical impact on health. People experiencing homelessness may be sleeping on the streets or in squats, hostels or poor-quality temporary bed and breakfast accommodation.
Homeless people are at increased risk of a range of health conditions including poor mental health, drug and alcohol-related conditions, tuberculosis, HIV, hepatitis B and C, influenza, oral cancer and type 2 diabetes (National Health Care for the Homeless Council, 2011). They are also at greater risk of developing co-occuring conditions. Difficult environmental conditions can lead to poorly managed long-term conditions. Severe mental health conditions, substance addiction, trauma and social isolation can compound these health risks.
Homeless people are more likely to die young, with an average age of death of 47 years old for men and 43 years old for women. This compares with a general life expectancy of 74 for men and 80 for women (Crisis, 2012). The average age of death of homeless people due to drugs is 34. Though this is similar to that of the general population, the chance of a homeless person dying from drugs is 20 times higher (Crisis, 2012).
Some 80% of homeless people report a mental health issue: 45% have a diagnosed mental health condition (compared with 25% of the general population), while 41% report a long-term health condition (28% in the general population) (Homeless Link, 2014). In the UK, the prevalence of TB is at least 34 times greater in homeless people than the general population and that of hepatitis C infection is nearly 50 times greater (Beijer et al, 2012).
This is a major public health crisis – and the lost years of life and missing contributions to public life are unacceptable.
Contact with health services
For homeless people, the amount of health risks and compounding factors they face mean visits to health services, including accident and emergency – which may be more accessible than other services – are inevitable. These visits present opportunities to treat immediate problems and start the longer-term process of support.
In this context, community nurses working with homeless people are a vital first step, reaching them at points of real need or crisis and providing invaluable support and care. However, nurses in all settings may come into contact with homeless people and can use the opportunity to support them on their journey towards stable housing or refer them to specialist services.
Community nurses in the QNI’s Homeless Health Network reach people in difficult circumstances, providing high levels of care and compassion. As part of a world-class health system, we want to see world-class care for homeless people. Homeless Link (2014) advises that ’anyone who becomes homeless should be offered a full health check and receive appropriate care for any physical, mental or substance misuse problems”.
According to a QNI survey of 269 nurses, only 85% of homeless people have this housing status recorded in their NHS medical records. This may prevent their access to the full range of support available.
Guidance for health professionals
Thanks to the work of the QNI’s National Homeless Health Advisory Group, Homeless Health Network nurses and patients with experience of homelessness, the QNI has produced:
- An assessment (health check) tool;
- Care plans to identify health needs.
Health professionals are encouraged to use them when checking these patients’ health.
The QNI’s health assessment tool was funded by The Monument Trust and launched in October on World Homeless Day. It can be downloaded free of charge.
It features a template health assessment, which includes key questions to ask homeless people about their general physical health, presence of long-term conditions, substance use, mental health, sexual health and housing. It also incorporates template care plans for nurses and patients.
The document highlights the need to treat homeless people holistically, and aims to coordinate care for this group. It is structured to help nurses and other health professionals work together in patients’ best interests and has been created to support and prompt professionals to ask the right questions, and undertake the right checks at the right time. For example, nurses should consider a full range of health assessment options, such as height and weight, blood pressure and heart and lung function checks, and check feet and oral health as part of an all-body assessment.
The guidance aims to promote the best standard of care for homeless people. It has been mapped to existing national standards such as those from the National Institute for Health and Care Excellence and the Faculty for Homeless and Inclusion Health’s standards for commissioners and service providers. The template is a nationally recommended resource.
The QNI (2015) states that, for nurses, the aim of assessing homeless people’s health is to help them improve it, manage health conditions and have the best quality of life. It also advises that ’nurses… use the opportunity presented by a health assessment to support patients on their journey towards stable housing, which will support improved health”.
To help support further professional learning, the QNI is developing a Transition to Homeless Health Nursing learning resource, targeted at nurses new to this field and due to be completed in June 2016.
Meeting patients’ needs
Before conducting a health check, the health assessment guidance advises nurses to gather local information about other groups and organisations to build multi-agency homelessness partnerships. It is also important to know the right protocols to follow when a person’s needs are identified.
Nurses and teams must be aware of the risks associated with working with potentially volatile individuals. The guidance recommends they be trained to handle conflict, and that organisational policies be put in place to support staff who may face intimidating and threatening behaviour.
Homeless people are entitled to treatment in primary care services regardless of whether they have an address. The guidance highlights the important role nurses and other health professionals play in identifying, treating and supporting people at risk of, or experiencing, homelessness. Given their increased risk of being in, or developing, poor health, the guidance recommends nurses work with other organisations to register and treat them. Nurses can register a person who has no address to help overcome barriers to treatment, and NHS England et al (2015) published guidance to clarify these rules (NHS England et al, 2015).
Individual health meetings with homeless people give nurses the chance to find out about their health needs, requirements and goals. The person’s goals may differ from the nurse’s but nurses can offer support, encouragement and advice, and work with individuals, to help them develop strategies to manage their own health. Guiding them to value their health is important – people with multiple needs may have low self-esteem and find it difficult to maintain good health.
If meeting for a planned intervention, homeless people may benefit from having a friend, carer or advocate at an appointment. Nurses need to inform them of their rights and remember it is the individual’s health appointment and priorities, not their own.
The guidance stresses that the aim of the assessment is for the nurse and homeless person to create the individualised care plan. The nurse, patient, carer(s), other professionals from health, housing and social care, and the voluntary sector may all have responsibilities for actions in the care plan – but achieving this requires a multi-agency infrastructure.
The guidance includes questions for nurses to consider post assessment (Box 1).
Box 1. Questions to consider
Are there any risks to myself, this individual, people around them or other staff members I need to communicate?
- What are the priority areas for immediate action?
- What causes the health problems?
- What is the sequence of the patient’s health problems – can anything be done to disrupt this sequence before it becomes problematic?
- What are the individual’s wishes for the future? Are these attainable?
Source: Queen’s Nursing Institute (2015)
Nurses are well placed to address health inequalities experienced by homeless people. This latest guidance and resources can bridge the gap between people and their health services and contribute towards ensuring the health needs of homeless people are met.
- Homelessness can have a critical impact on health
- Interventions from a mix of professionals are essential so patients get the support they need
- Homeless people may have had negative experiences and relationships, and community-based health workers have a role to play in helping them to feel valued
- Nurses need guidance on best-practice areas when assessing the health of a homeless patient
- The aim of an assessment meeting is for the nurse and patient to create a care plan together
Beijer U et al (2012) Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic review and meta-analysis. Lancet Infectious Diseases; 12: 11, 859-870.
Crisis (2012) Homelessness Kills: An Analysis of the Mortality of Homeless People in Early Twenty-first Century England – Summary.
Homeless Link (2014) The Unhealthy State of Homelessness: Health Audit Results 2014.
National Health Care for the Homeless Council (2011) Homelessness and Health: What’s the Connection?
NHS England, Commissioning Operations, Primary Care Commissioning (2015) Patient Registration: Standard Operating Principles for Primary Medical Care (General Practice).
Queen’s Nursing Institute (2015) Assessing the Health of People who are Homeless: Guidance with Health Assessment Tool (2015).