How Primary Health Networks can commission primary care services to better meet the health needs of people experiencing homelessness
Through our work across the health and social services sectors, we recognise the complex intersection of healthcare and homelessness and that mainstream systems are generally failing to meet the needs of this vulnerable cohort. In this article, we aim to explore the commissioning implications for Primary Health Networks seeking to improve access to primary care services for people experiencing homelessness.
The insights below draw from a previous project supporting a PHN to review and re-commission a specific homeless health care service. The project involved policy scanning, desktop research, service mapping and consultation with local stakeholders. While the project’s findings focus on one specific geographic area, we believe there are implications for commissioning by PHNs more broadly.
The complex and often unmet health needs of people experiencing homelessness
People experiencing homelessness encounter considerable systemic challenges in accessing healthcare services, resulting in significant disparities in health outcomes compared to the general population. These health inequities are rooted in broader issues such as socioeconomic disadvantage, lack of stable housing, discrimination, and experiences of mental health issues, trauma and violence.
Mainstream healthcare services often fail to adequately address the unique needs of this population due to a mix of inadequate resourcing, stigma, capability and intent — in addition to the broader systemic challenges in Australia’s healthcare system, such as regional gaps (services and workforce), lack of coordination and integration between acute primary care, and a system that is not well built to respond to chronic and complex conditions, all of which is disproportionately felt by those experiencing homelessness.
While a recently published Inquiry into homelessness in Australia in 2021 showed relatively stable rates of homelessness in Australia between 2001 and 2016, early indications since the 2021 Census (which is the most recent data point but likely masks the actual rate due to pandemic-era responses) are that the prevalence of homelessness — ranging from those sleeping rough through to those in temporary accommodation or inadequate housing — is continually increasing as a public policy priority in Australia.
A recent National Productivity Commission inquiry highlighted the prevalence of mental illness amongst the homeless population and called for service reform to better support this cohort through integration and coordination between the health and homelessness systems. The Inquiry’s report recommended scaling up ‘Housing First’ Programs with integration from multiple agencies that involve:
targeting people with a mental illness or complex health needs
coordination of services and supports
multidisciplinary teams
intensive contact
single care planning
information sharing.
It reflects a recent review that proposed a best practice model to improve health outcomes for people experiencing homelessness nationally consisting of six components:
Housing as a health solution — including ‘housing first’ approves and supporting people to re-engage with healthcare
Continuity of care — trained staff working across the system using case management
Hospital in-reach — bringing specialist GP care into hospitals and linking admitted patients to community-based services
Specialised practices — with integrated services to connect health with other sectors
Medical respite centres — for people to reside when they are unwell, sleeping rough but not requiring a hospital admission
Outreach — mobile/street outreach and ‘pop-up’ clinics in known/trusted settings.
Policies and programs supporting people experiencing homelessness
While Australia has a National Housing and Homelessness Agreement (NHHA) — the primary public investment in supporting and addressing homelessness — there is limited reference to health care services (or primary care specifically). Specialist homelessness services (SHS) funded by the NHHA are the primary responsibility of state/territory governments and generally focus on housing and social support without direct health care provision.
Similarly, Australia’s Primary Health Care 10-year Plan identifies challenges of mainstream primary health care services to deliver primary health care for people with complex needs and/or experiencing socioeconomic disadvantage without specifically prioritising the health needs of people experiencing homelessness.
Despite the recent national inquiry calling for a coordinated approach with more distinct accountability between various levels and agencies of government and collaboration with non-government organisations, there remains minimal explicit policy intent recognising the intersection between health and homelessness.
Primary Health Networks (PHNs) across Australia are addressing the health needs of people experiencing homelessness as part of their remit at a regional level.
Several PHNs have commissioned varying service models that specifically targeted people experiencing homelessness in the past, often through the PHN After Hours Funding Program. A national evaluation from 2020 identified about 5% of all after-hours funding targeted people who are or are at risk of being homeless.
And more recently, the Department of Health made an additional $15 million in funding available in 2023 to PHNs through the PHN Homelessness Access Program that aims to “support primary health care access for people experiencing homelessness and those at risk of homelessness.” Several PHNs are currently undertaking health needs assessments with a specific focus on homelessness to help inform future commissioning activities.
Examples of specific homeless health services
A review of homeless health care models in regions across Australia shows diversity in how they are delivered and funded — this includes mobile outreach, fixed site, and in-reaching models and varies between PHN, government, philanthropic and enterprise-funded services.
Examples include:
Wheels of Wellness, a Cairns-based charity that delivers outreach and clinic medical services alongside non-clinical respite to homeless and other disadvantaged community members
Homeless Healthcare, a non-profit in Western Australia established by a GP in 2008, offers services and programs like hospital in-reach, after-hours outreach, a fixed site ‘Hub’ and a medical respite (short stay) facility.
Street Side Medics, a GP-led medical service for homeless communities in NSW is delivered via a mobile van through collaboration with other homeless charities, shelters and services
Mobile Outreach Support and Health Program provided by Drug Arm, offering integrated medical, nursing and other support services through outreach in the after-hours period
Micah Projects delivers Street to Home, an outreach service offering housing and healthcare (nursing) services and an Inclusive Health and Wellness Hub – an integrated primary healthcare service for people experiencing disadvantage, including homelessness.
State/territory government health bodies also commission a range of services related to but often not integrated with PHN-funded or general primary care services. For example, in Queensland, the Queensland Government has invested in several ‘integrated health and housing responses’ that generally aim to equip either homelessness services with additional health capability (e.g. nursing) or develop hospital-led homeless health outreach teams (HHOTs) with varying levels of integration with the local primary care sector, often dependent on local relationships between clinicians across settings.
While previous program evaluations (here and here) suggest positive outcomes in terms of service accessibility and connection with mainstream services, many of these services still operate largely independently of each other and limit integration between services and systems.
Commissioning Considerations for PHNs
Mainstream primary care services are generally not equipped to meet the health needs of people experiencing homelessness. PHNs play a central role in addressing these inequities and helping shape a more coordinated and integrated approach called for in the recent national Inquiry into Homelessness in Australia.
While providing funding for services may be one aspect of that role, there is a range of valuable activities that PHNs can undertake at a regional level, spanning service planning, commissioning, practice support and system integration.
Some key activities that PHNs should consider include:
To understand the unmet need for primary health care services for people experiencing homelessness as an explicit priority within their Health Needs Assessment (HNA) and regional planning activities, particularly in the areas of mental health, alcohol and other drugs, aged care, maternal health, sexual health, chronic conditions, and Domestic and Family Violence (DFV).
Providing targeted funding of primary health care services that demonstrate improved access for people experiencing homelessness — particularly models that include a mix of outreach and clinic-based services, available during both the ‘in-hours’ and ‘after-hours’ periods, and reflect a safe and compassionate environment tailored to the needs and preferences of people experiencing homelessness
Creating integrated care pathways for patients experiencing homelessness who have complex care needs under a "single care plan". The plan should outline the involvement of usual general practice and allied health services, public specialist outpatient services, emergency departments and Aboriginal Medical Services.
Brokering partnerships between primary care services (particularly general practices and Aboriginal Medical Services) and local specialist homelessness services to work towards a more integrated approach where an individual’s health is one domain of addressing housing vulnerability and homelessness. It should explore:
Formalised arrangements or commitments with regional specialist homelessness services to outline roles, responsibilities and service-level expectations;
Patients identified as experiencing homelessness being proactively recognised and connected with specialist homelessness services to address their homelessness and housing vulnerability, and;
Case conferences and other mechanisms that enable coordination and information-sharing, including a person’s nominated housing caseworker.
Ensuring contract management, monitoring and evaluation, and periodic program reporting arrangements of relevant PHN-commissioned services recognise and provide visibility of people experiencing homelessness as a ‘priority population’.
Building the capacity and capability of local primary care services, particularly general practices who do or may consider doing outreach work or clinics targeting homeless communities, through the expertise of a PHN’s primary care engagement team. This advice or support might cover
quality improvement and clinical governance
optimal use of primary care data
digital health initiatives
optimal billing
referral pathways
workforce recruitment and development
representation in advisory committees and consultation
Promoting existing PHN-commissioned services to co-locate or reach into existing homelessness support services (e.g. ‘hubs’) to extend their reach and engagement into settings where people experiencing homelessness are likely to know and access.
Engaging agencies who also provide funding for homelessness support services — such as local hospital networks (e.g. HHSs, LHDs), state/territory government housing departments, local governments/councils and philanthropy — to align or co-commission services being funded.
Across any of these activities, effective planning and commissioning of primary care services for people experiencing homelessness requires PHNs to continually hold a deep understanding and careful consideration of the health and service needs of their communities to address inequities in an environment of limited resources.
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