Three steps to improve the mental healthcare of people experiencing homelessness
This submission to the Royal Commission into Victoria’s Mental Health System highlights the urgent need for housing to improve the mental healthcare of people experiencing homelessness.
Launch Housing is an independent Melbourne-based community organisation working with people at risk of or experiencing homelessness. We believe housing is a basic human right that affords people dignity, and it is our job to make this happen. Our mission is to end homelessness. We provide flexible, specialist services that directly assist thousands of individuals, couples and families every year. [Appendix 1]
Co-occurrence of mental ill-health and homelessness
For Launch Housing, the Royal Commission will be judged by how it responds to Victoria’s most vulnerable citizens – people with the co-occurrence of mental ill-health and an experience of homelessness [Appendix 2] [Appendix 3].
Mental illness contributes to and is exacerbated by the stress and trauma of homelessness. This group, often cycle through acute mental healthcare and exit to homelessness, only to return repeatedly to hospital-based care, and sometimes the prison system. Along the way, they incur a high mental health cost to themselves and a high financial cost to governments.[Appendix 4].
Housing is foundational for good mental health
Access to housing is foundational for the prevention of, and recovery from mental ill-health. As a society we have demonstrably failed to put this seemingly obvious prescription into practice. Without secure housing and an accessible mental health system, someone’s recovery from mental ill-health is seriously compromised.
Unfortunately, people with mental ill-health are more likely to be in unaffordable housing, which compounds stress and can also lead to poorer mental health outcomes.
Based on recent interviews conducted by Launch Housing, we sadly know how the mental health system repeatedly and damagingly fails this group [Appendix 5] [Appendix 6], sometimes with tragic consequences [Appendix 7].
Mental Health and Housing Systems have failed
One systems failure, as noted in an AHURI report into mental health and housing pathways is the simple lack of access to good mental healthcare. The extraordinary fact is that many people experiencing homelessness, including those with high needs, do not access or use mental health services.
The ability to secure mental health assessments and other clinical health interventions in a timely manner is crucial. And even when mental healthcare is provided this can sometimes be episodic and haphazard. The uncertainty and transience of homelessness, including rough sleeping, is certainly a contributing factor.
Three steps to improve the mental health of people with a chronic experience of homelessness
These critical issues need a remedy. Fortunately, there are known and scalable solutions. These do not preclude additional interventions suggested to the Royal Commission by others, but these three steps will significantly improve the mental healthcare needs of people with an experience of homelessness, especially those with high needs.
1. Prevention programs that sustain a rental tenancy
More prevention and early intervention services are required. In particular, there is immense value in programs that sustain a rental tenancy when someone has a mental health episode [Appendix 8 ]. With a persistent shortage of affordable private rentals and an under-supply of social housing in Victoria, sustaining someone’s tenancy is critical.
This need is highlighted by the fact that the majority of households seeking support from specialist homelessness services were housed in precarious circumstances, and were at risk of homelessness.
Nationally, among those accessing specialist homelessness services, 52% of clients with a current mental health issue needed long-term housing assistance compared with other clients. Rental brokerage models provide financial and practical assistance to establish and maintain private rental tenancies for people who are at risk of or experiencing homelessness.
For example, Launch Housing’s Tenancy Plus program helps establish and sustain public and community housing tenancies. A critical gap, however, is the lack of similar programs for private renters.
2. Programs that support the timely transition to appropriate housing
It is also critical for the Royal Commission to address the interaction between acute mental healthcare in hospitals and housing. Hospitalisation is common among adults who are experiencing homelessness and mental illness typically deteriorates without a safe place to live. Hence our second step is the provision of ‘step down’ programs, or programs that support the timely transition to appropriate housing when exiting hospital following a mental health episode [Appendix 9].
The chronic shortage of affordable housing in Victoria results in more than 500 people being discharged from acute mental healthcare into rooming houses, motels and other forms of homelessness each year. Discharging someone into homelessness is completely unacceptable.
Programs like Launch Housing’s Housing Mental Health Pathways Program works to support acute mental health patients with a history of homelessness who have no suitable accommodation at the time of discharge from hospital. But more is required.
Better ‘step-down’ or medical respite services would drastically improve discharge processes. Medical respite enables people who experience homelessness to recuperate after hospital in a more home-like environment . A systematic review of American research showed that medical respite programs reduce future hospital admissions, inpatient days, and hospital readmissions. They also result in improved housing outcomes.
Programs like the Sister Francesca Healy Cottage (The Cottage) run by St. Vincent’s hospital provide a supportive, home-like environment and a range of services to people who are at risk of or experiencing homelessness. Sadly, such important services are in short supply.
3. More permanent supportive housing
Our third and final step is increasing the number of permanent supportive housing options for those who are prone to episodes of mental ill-health and are heavy users of health, criminal justice and crisis-related homelessness and housing services [Appendix 10 ].
Permanent supportive housing ensures the provision of ongoing, long-term housing coupled with supportive services for individuals and families experiencing chronic homelessness.
The critical components of permanent supportive housing are long-term housing matched with voluntary supportive services including access to mental healthcare and medical services.
Evaluations of this approach demonstrated that it is an appropriate model to assist people with chronic experiences of homelessness who need support to access and sustain their housing. And it also makes financial sense for governments.
The evaluation of Common Ground Brisbane represented a cost saving to the Queensland government of almost $15,000 per person per year.
Political follow through is needed this time
Past reviews of Australia’s mental health system have resulted in missed opportunities for action. This Royal Commission offers an opportunity for governments at all levels to ensure the fundamental role of housing is addressed when implementing changes to the mental health system.
Unfortunately, people’s housing needs are effectively ‘invisible’ to the mental health system. There seems to be the presumption that patients are either well-housed or are living somewhere.
Yet, the key healthcare intervention for someone experiencing homelessness is access to affordable, stable accommodation and community support to maintain their housing whilst dealing with mental health issues. Without a place to live it is nearly impossible to take care of one’s mental health needs.
Simply put, housing is good mental healthcare.