The programme is accessible because it is user-friendly and not bureaucratic, and it is acceptable because it is a low-threshold service, with the doctors providing their services in the facilities for the homeless at regular hours. Moreover, it is acceptable to the homeless because it is unnecessary to make an appointment and waiting times are appropriate.
The programme is also acceptable to the homeless because it takes into account their special needs. Furthermore, within the programme, the homeless are accepted as they are, thus avoiding discrimination, and their treatment costs are generally covered either by health insurance or medical assistance. Even where expenditures are not covered by health insurance or medical assistance, the patients are not charged for the services. If they are charged, the costs are covered by the project itself.
As already mentioned, the programme is sensitive to gender requirements, taking into account the special needs of women living on the streets, such as experiences of violence and rape. Also, the health of the homeless is much worse than that of other people the same age. Thus, they need more medical services at a younger age and need care earlier in life.
Confi dentiality is a basic principle of the programme. Although doctors exchange information about the patients among themselves, they pass on information – for example, to social workers at the shelter – only if they get the patient’s consent.
Exceptions are made for patients that might endanger themselves or others, but these cases are very rare.
Besides carrying out medical documentation, the programme regularly carries out self-evaluations, although no funds are available for evaluation. For such evaluations, programme partners (such as F.E.M, Psychosocial Service of the City of Vienna and social workers) are consulted by questionnaire. Also, programme clients are interviewed personally, because questionnaires are too diffi cult to use for many in the target group, due to poor reading and writing skills. Results from the evaluations showed broad acceptance of the health care services provided for the target group. Social workers running homeless shelters, as well as psychiatrists from Psychosocial Service of the City of Vienna, experienced the assistance of neunerHAUSARZT as an important additional resource that made their work easier. Thus, the evaluations proved that nearly all stakeholders were very satisfi ed with the service.
The results of the evaluations strongly supported the necessity of interdisciplinary cooperation among physicians, social workers, psychiatrists and psychologists. As a result of the self-evaluations’ aim of improving the quality of care, treatment of inhabitants’
psychiatric disorders increased considerably, which also led to a more confl ict-free atmosphere at the shelters. Also, analysis of medical data resulted in a rearrangement of health care provision by the physicians of neunerHAUSARZT. Moreover, because occupants of hostels for long-term homeless people showed the poorest health status, more service capacity was shifted to them.
References
Anonymous (2007). Medizinische Betreuung Wohnungsloser in Wien – Gesundheit ohne Schwellenangst. Medical Tribune (Vienna), 22 August 2007, 39:31–34 (http://www.medical-tribune.at/dynasite.cfm?dsmid=82346&dspaid=643785, accessed 11 June 2008).
Dimmel N (2001). Krankheit und Armutsrisiken. In: Tálos E, ed. Bedarfsorientierte Grundsicherung: Rahmenbedingungen – Umsetzungserfordernisse – Folgen. Vienna, Mandelbaum:327–384.
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Eurostat (2007). Data navigation tree [online database]. Luxembourg, Statistical Offi ce of the European Communities (http://epp.eurostat.
ec.europa.eu/portal/page?_pageid=1090,30070682,1090_30298591&_dad=portal&_schema=PORTAL, accessed 26 September 2007).
Federal Ministry of Health and Women (2006). Public health in Austria. Vienna, Federal Ministry of Health and Women (http://www.bmgfj.gv.at/
cms/site/attachments/8/6/6/CH0713/CMS1051011595227/public_health_in_austria_2005_internet.pdf, accessed 10 June 2008).
Fuchs M, Schmied G, Oberzaucher N (2003). Quantitative und qualitative Erfassung und Analyse der nicht-krankenversicherten Personen in Österreich. Vienna, Federal Ministry of Health and Women (http://bmgf.cms.apa.at/cms/site/attachments/4/6/5/CH0083/CMS1083763194914/
ebnkv-end-internet.pdf, accessed 11 June 2008).
Hauptverband der österreichischen Sozialversicherungsträger (2007). Handbuch der österreichischen Sozialversicherung 2007. Vienna, Hauptverband der österreichischen Sozialversicherungsträger.
Perl C, Schoibl H, Zuschnig B (2006). The right to health is a human right: ensuring access to health for homeless people. Vienna, Austrian National Report for the European Federation of National Associations Working with the Homeless.
Pfeil WJ (2001). Vergleich der Sozialhilfesysteme der österreichischen Bundesländer. Vienna, Federal Ministry for Social Security and Generations.
Establishing a programme that enters uncharted terrain in Vienna (and Austria) was quite challenging, especially in negotiating with different partner institutions for funding and support. Social workers in charge at the different shelters, for example, had to be convinced that their target group would profi t from a regular on-site health service, which was not obvious to them at the beginning.
When the project’s fi rst summer approached and the project manager, Barbara Zuschnig, addressed the organization of holiday replacements for physicians, the feedback from the hostels indicated that this was not needed. Although she disagreed with them, she accepted the social workers’ decision. In the programme’s second summer, however, each physician was asked to organize a holiday replacement because the social workers did not want to continue without on-site health service. According to Ms Zuschnig (neunerHAUSARZT, personal communication, September 2007), “You have to be patient, you have to be able to even endure developments you dislike and act fl exibly when trying to match the aims of the programme with realities.”
When starting the project, its initiators were confronted with several administrative problems. Because each physician was practising medicine at several shelters and no mobile e-card readers were available, it was necessary to develop (with WGKK) a suitable administrative method for keeping track of the patients and for accounting for services. Also, a completely new model for remunerating physicians’ work had to be established, because four physicians shared one full-time position.
The initial programme concept envisioned establishing an outpatient clinic for the homeless, in addition to the medical care in the hostels. Because of insuffi cient funding, this idea could not be realized until now. Also, a dental practice is planned.
Moreover, a gynaecologist is being sought. Starting in 2008, male occupants will be able to make use of psychosocial counselling for men, carried out by MEN.
The programme also reaches target groups that formerly did not seek assistance. Three quarters of the patients accessing the health service at the shelters did not have a family practitioner. Therefore, physicians expect a growing demand. Right now, although the four physicians cope with the number of patients, there is a plan to enlarge the team by two physicians. This was expected, because the programme concept already included the possibility of training physicians how to treat the homeless according to their needs.
Evaluation is important for quality control of the project’s health services. Funding for evaluation, however, is still lacking.
To establish a similar programme in other Austrian federal states or in another region, the local structures have to be taken in account, because stakeholders, political contexts and social systems differ from country to country, and even from region to region. For the programme to be adapted to other places, profound knowledge of existing services and structures of the health care system is of utmost importance for successful planning and implementation.
Austria
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Republic of Austria (2006). Nationaler Bericht über Strategien für Sozialschutz und Soziale Eingliederung. Vienna, Republic of Austria (http://
www.bmsk.gv.at/cms/site/attachments/0/7/5/CH0335/CMS1083929522616/strategiebericht_sozialschutz.pdf, accessed 5 November 2007).
Schoibl H (2005). Review of policies on homelessness in Austria 2004–2005. Salzburg, Bundesarbeitsgemeinschaft Wohnungslosenhilfe (http://www.bawo.at/_TCgi_Images/bawo/20061103165158_Review%20of%20policies%20on%20homelessness%20in%20Austria%20(2)_1.
pdf, accessed 28 September 2007).
Springer S (2000). Homelessness: a proposal for a global defi nition and classifi cation. Habitat International, 24:475–484.
Statistik Austria (2006). Statistisches Jahrbuch Österreichs 2007. Vienna, Statistik Austria.
Statistik Austria (2007). Einkommen, Armut und Lebensbedingungen 2005. Ergebnisse aus EU-SILC 2005. Vienna, Statistik Austria.