Abstract
Background: Individuals experiencing homelessness have higher rates of chronic and mental health conditions and mortality, and face challenges accessing primary care due to a lack of affordability and availability, other competing priorities and stigma. A lack of access may also mean higher use of acute services. Virtual health care can reduce health inequity but needs user acceptance and address issues of digital literacy, access to technology, on-site assistance and private spaces for homeless people.
Approach: A pilot Virtual Health Hub (VHH) for people experiencing homelessness in Sydney, Australia provided virtual general practitioner (GP) and psychological care within a crisis accommodation service. This included nursing assistance. This region holds a substantial population of individuals experiencing homelessness and residing in boarding houses. The VHH Model of Care trial was a collaboration between Homeless and Rough Sleepers Program within Clinical Services Integration and Population Health and RPA Virtual Hospital (rpavirtual) in Sydney Local Health District (SLHD), and the crisis accommodation setting. The VHH evaluation assessed feasibility of the service specifically examining accessibility, efficiency, costs, technology, quality, and outcomes through attendance data, patient experience measures, stakeholder interviews and case studies. The evaluation project was overseen by an evaluation Working Group consisting of representatives from UNSW, Homeless Program and rpavirtual in SLHD, the crisis accommodation setting staff and a Lived Experience Consultant.
Results: Data indicated 40% client utilisation with high attendance for GPs and/or psychologists. All clients reported high quality of care; appointment benefits; understanding clinicians; treatment help; and that privacy was maintained. If the VHH was not available, one third would not have sought treatment. The majority agreed that virtual care was the same or better than in-person care. Only a few experienced technical issues. Service provider interviews indicated benefits of accessible and affordable care; perceived reduced hospital presentations; staff time saved; and reduced client costs. Limitations were a lack of physical examinations and primary care follow-up due to temporary accommodation. Strong stakeholder partnerships enabled implementation success.
Implications: The VHH service is feasible and replicable with the on-site assistance and stakeholder commitment. The study contributes to existing knowledge of the utilization of digital primary health care for people experiencing homelessness by adopting an implementation outcome framework. The framework assists to understand to what extent the digital health intervention which facilitates accessibility is acceptable, appropriate, feasible, and how it could be sustained in the crisis accommodation. It is important that public health practi-tioners do not assume that these aspects of health program implementation would be similar between the general population and vulnerable population. Moreover, this study also unravels the high demands of seeing psychologists among people experiencing homelessness with a mental health condition. This high demand can be considered as unanticipated needs. The VHH filled these needs of addressing mental health issues and benefited first experience of psychological service for this specific population.