Vulnerability Index, Brain Injury and Chronic Homelessness 2013
Felicity ReynoldsCEO, Mercy Foundation &Chair,Australian Common Ground Alliance
Some background about terminology. A bit about Hwang’s US research into braininjury and chronic homelessness. What is theVulnerability Index (VI)? What has theVI told us about brain injury andchronically homeless people in Australia? What might all this mean?
First – whyTBI instead of ABI. TBI is more commonly known as acquired brain injury(ABI) in Australia. I prefer the termTBI, as it more accurately describes thelikely method by which the injury was ‘acquired’. It speaks to the likelihood of a traumatic and, possiblyviolent, childhood, as well as theTBIs that can be acquiredwhen you have to cope on the streets and live in unsafeplaces, the violent experiences of prisons and otherinstitutions and, of course, the experiences of beingregularly intoxicated and falling down a lot.These are allways in which someone might do permanent damage totheir brain.
Hwang (2007) – a study onTBI with 1200 homelesspeople. Summary results: Lifetime prevalence ofTBI in a representative sample of homelesspeople is more than 5 times greater than in the U.S. generalpopulation TBI prevalence among homeless people is within the range reportedamong prison inmates. FirstTBI usually occured prior to the first episode of homelessness History ofTBI strongly associated with wide array of adverse healthoutcomes. Cognitive consequences ofTBI may increase the risk of subsequentmental health, alcohol, and drug problems. However, pre-existing mental health, alcohol, and drug problems mayincrease the risk of experiencingTBI.
Clinicians should routinely screen homeless patients for history ofTBI. TBI should be considered a possible cause of neuro-psychologicaldysfunction and behavioral problems. Further efforts should be directed at the management ofTBI-relatedproblems such as impulsive behavior, and the treatment of co-occurringalcohol or substance abuse. Persons with brain injuries may have attention deficits, making it difficultfor them to focus on tasks and understand, remember, or respond todirections. These individuals may need more time to follow instructions; slownessshould not be misinterpreted as a lack of effort or cooperation. TBI-related brain dysfunction can predispose to irritability or impulsivitythat should be understood in the context of the person’s previous injury.
Many of you work in organisations that see homelesspeople daily and you know the context.The followingis about a methodology for knowing, doingsomething and measuring outcomes. What is theVulnerability Index? Some of you already know (and have been directlyinvolved here in Sydney). For those that don’t....it is not an ‘assessment tool’, itis a practice instrument and methodology for a localcampaign to locate chronically homeless people,complete aVI survey to better understand their healthand housing needs and then to work with them toachieve a housing goal (PSH – if relevant).
Huge coincidence! Hwang was actually theco-author of research (done in the 1990s withDr Jim O’Connell, on which theVI is based).That particular research was broader andlooked at all the health vulnerabilities ofchronically homeless people. They found 8 vulnerability factors that putpeople who were homeless (compared topeople who were housed) at greater risk ofdeath.
6 months homelessness or longer and…… End Stage Renal Disease History of Cold Weather Injuries Liver Disease or Cirrhosis HIV+/AIDS Over 60 years old Three of more emergency room visits in priorthree months Three or more ER or hospitalisations in prior year Tri-morbid (mentally ill+ abusing substances+medical problem)
An additional 3 vulnerability factors: Alcohol everyday in past 30 HIV+/AIDS Injection Drug UseQuick description of methodology for RegistryWeeks and next slide – Registry Week’s withVI in Australia, since 2010.
425561484633211093211680 people surveyed as at August 2012158
76% male 22% female Most of the population surveyed werebetween 36 and 55 (54%) years old 23% identified as Aboriginal or Torres Straitislander.(Note these statistics don’t include Perth)
28% had been in foster care 75% had spent time in police cells 53% had been in prison Half (773) of the number surveyed (1522) hadnot been housed at all in the past three years 26% had been housed/re-housed 3 times ormore 6% had been housed/re-housed 10 times ormore.(Note these statistics don’t include Perth)
Homeless historyAverage age and time homeless - by region6 10 9 15760102030405060Brisbane Sydney Melbourne Townsville Hobart Western SydneyAverage age Average years homeless44 45 44 48 38 40Sample size = 1522
61% reported a mental health condition 51% reported having received treatment for aMH condition 73% reported drug/alcohol abuse 46% reported having received treatment fordrug/alcohol abuse 51% had been the victim of a violent attack 24% reported a disability that limited theirmobility
29% reported a brain injury orhead trauma. Yes....almost a third of all respondents (withsignificant histories of homelessness) SELF –reported a brain injury or head trauma.
So, perhaps those chronically homelesspeople who are ‘treatment resistant’ or ‘non-compliant’ might actually not be able toremember appointments too well.They mayhave impulse control problems. Theymay need to be supported in a differentway.They may need some extra help toremember things (as just one example). If suspected, a neuro-cognitive assessmentshould be arranged.
All chronically homeless people need housing tosolve their homelessness and some may alsoneed ongoing support to sustain housing (PSH). This is KNOWN (not guessing) to include almosta THIRD of all chronically homeless people whomay have problems caused by aTBI - and requirepermanent (not transitional) support to sustainhousing. (Additional evidence for this need is theircurrent state of long term homelessness.)
Permanent Supportive Housing is the onlyanswer for people with significantTBI and chronichistory of homelessness. Through theVI, we have gained a betterunderstanding of how many (and who they are –and some are now in PSH) in the chronicallyhomeless population may need this type ofongoing support to sustain housing. In fact, there could also be a number of thispopulation who may require significant (including24 hour) care (but more specialist assessmentinformation would be needed).