Multidisciplinary Collaboration for People Experiencing Homelessness with a Severe Mental Illness
Emily Lyons, Social Worker, Kristen Lewis, Occupational Therapist and Kathleen Walsh, Registered Nurse, Homeless Outreach Psychiatric Service, Alfred Health
Working with people that are homeless with a severe mental illness requires a collaborative multidisciplinary team approach to provide comprehensive treatment and case management. As clients present with complex psychosocial needs, to ensure all these needs are met requires collaborative and creative interventions. To encompass the complex nature of the work, the Homeless Outreach Psychiatric Service (HOPS) has developed a team based approach where all disciplines actively contribute to day to day care and in all stages of treatment planning.
Alfred Health in Melbourne, Australia is a tertiary health care service providing acute medical and surgical services, emergency and critical care, aged care, diagnostics, rehabilitation, allied health, mental health, palliative care, and residential care.
As a department of Alfred Health, Alfred Psychiatric Services provides mental health care to a client population based on local government boundaries of the Inner South. The service provides treatment and support to individuals aged between 16 and 64 across the municipalities of Port Phillip, Stonnington and Glen Eira-Caulfield who are experiencing serious mental illness. This is a diverse population of approximately 315 533 residents (1)(Australian Department of Statistics 2011).
At any point in time, approximately 1000 people are receiving comprehensive ongoing clinical mental health support across the continuum of care from more than 200 multi-disciplinary staff. Services are delivered by different teams and units within the mental health service and are geared to different phases of care. The service operates acute in-patient units with a total of 58 beds and two community mental health clinics. Within each clinic there are various different teams that meet the needs of the client group within the community, including the HOPS team.
The HOPS team has various roles and expectations; these include provision of specialist clinical and treatment responses for people who do not readily engage with mental health services and are homeless or at risk of homelessness. The HOPS team utilises assertive outreach to locate and engage with clients to develop a pathway out of homelessness by providing early intervention, treatment, coordination of services and links with support services. Another role for the HOPS team is the ongoing collaboration and the relationship with homeless service agencies. There is also the expectation of providing secondary consultations and assessments to homeless services and mental health workers (2).
The Alfred HOPS team operates Monday to Friday between the hours 0800-1630hrs, and work with a caseload of up to 40 clients, however this may vary depending on demand, complexity and staff capacity. The team consists of registered nurses, a social worker and an occupational therapist; the team also has a consultant psychiatrist (0.57 EFT) and psychiatric registrar (1.0 EFT). The team works in a collaborative team based manner, utilising all disciplines in a collaborative approach to client care. The team provides assessment, follow-up, treatment, secondary consultation, education and outreach. HOPS has the unique ability to spend longer periods of time and be creative with interventions to build relationships in order to work towards securing accommodation, monitoring mental health and providing comprehensive case management
As well as drawing on the clinical skills within the team, Alfred HOPS has the benefits of partnerships, both formal and informal, with local community services. The Inner South region is rich with homeless services and HOPS has been able to develop relationships that result in the exchange of advice, formal education and specialist skills. The HOPS team has two partnerships with local homeless agencies - Sacred Heart Mission and Hanover Southbank Crisis Accommodation facility; HOPS also works closely with other teams within the Alfred Psychiatric Service.
HOPS accepts referrals from our partners, Sacred Heart Mission and Hanover Southbank, from within Alfred Psychiatric Services as well as the wider community. Clients may be referred while under treatment in mental health services or untreated. Clients present with severe mental illness and a history of homelessness, transience or a history of poor engagement with mental health services. Clients also typically present with a range of complex psychosocial needs which adds a layer of complexity to treatment and case management. Clients may present with any number of needs, including substance use and abuse, physical health needs, contact with the forensic system, histories of trauma and abuse or domestic violence, financial management, social isolation and estrangement from support networks and contact with other service systems. Clients may be voluntary or treated under the Mental Health Act.
The greatest challenge of working with this client group is being able to engage with the client in a meaningful way. The work of HOPS is initially to engage a client who potentially has years of poor experiences with service systems, and faces complex challenges on a day to day basis. Following engagement and building a supportive and therapeutic relationship, HOPS are then able to assist the client to address a range of complex needs. The client’s immediate needs of food, shelter and healthcare are paramount in the first interaction between HOPS and clients referred from our partners.
One of the main challenges for this client group is finding suitable long term housing, which can take years to achieve given the current housing crisis and often results in many moves with clients being housed in inappropriate housing exposing them to further violence and substance use. HOPS clients can move multiple times in short periods of time, which can pose challenges when attempting to work with clients who are difficult to engage. The nature of severe mental illness and associated behaviours or choices creates further challenges in finding suitable housing and in maintaining housing. Long term housing for clients with support needs is difficult to find, and clients may be excluded due to substance use or past behaviours.
The complex nature of this client group poses challenges on a daily basis for case managers and the medical team. The day to day work with clients can be across several domains, including stabilisation of mental state and risk assessment, attempting to ensure medication compliance while clients are sleeping rough, assisting clients with substance use, assistance with day to day activities, basic health care, liaison with a range of services including financial management and liaison with the legal system and providing support and space to address the clients own needs.
Work with this client group is often slow and can take many years of engagement and several episodes of care before traditional notions of recovery can be seen. In the team the nature of success often means the client is willing to work with the team, or at the very least is accepting of our role within their life at this time. It is only through good engagement and building a strong relationship with the client from a whole team approach that this work can be attempted and longer term benefits can be possible.
Due to the complexities of our clients, their needs and the broad systems and services that we work within, clinicians are required to use a wide range of skills. As previously mentioned HOPS consist of a number of different disciplines. Each discipline brings with it a set of skills, knowledge and different perspectives on how to engage and work with clients. The team will focus on not only the psychiatric and medical needs of our clients but also draw from the theories of psychiatric nursing, occupational therapy and social work to be able to provide collaborative care. HOPS has developed a team based approach where input from all disciplines is sought and valued and the team as a whole is responsible for each client’s care.
On any day a HOPS clinician is required to address a number of issues regardless of their background and training. Whilst constantly attending to a client's mental health, clinicians also take on a number of different roles to address the complex psychosocial needs of our clients. To be able to do this each clinician builds up a set of skills and knowledge that can help them address the client’s needs, whether that is knowing how to navigate through housing systems or assisting clients to address physical health issues.
To address complex needs a clinician must experience and learn different approaches to client care that may vary from their training and traditional skill set. There is a constant exchange of information, theories, experience and ideas between the disciplines in both a formal and informal manner. This includes clinical supervision, joint visits, weekly progress review of clients and formal clinical reviews of treatment plans.
Working with clients who are homeless and have a severe mental illness is challenging and complex. To create pathways to recovery and to address the complex psychosocial needs of clients including long term stable and suitable housing, creative interventions are required. The knowledge, theory and experience from these disciplines is utilised collaboratively to influence the types of interventions applied. This shared approach to client work allows for the use of a range of interventions in an attempt to create meaningful working relationships and to facilitate a positive experience of mental health services for clients, possibly facilitating sustained change in an individual’s life. HOPS will continue to draw on our range of skills throughout the disciplines in an attempt to create meaningful and recovery focused care, creating pathways out of homelessness and assisting to stabilise client’s mental health.
Endnotes
1. Australian Department of Statistics 2011, 2011 Census Data by Location viewed 2nd February 2014,
2. Victorian Government 2011, Adult specialist services 16-64years viewed 2nd February 2014,