129 Management of destitute homeless patients in the emergency department of Toulouse University Hospital

Background and Objectives People with poor living conditions have a poor state of health, with a high rate of early deaths and a life expectancy that may be 30–35 years shorter than that of the general population. Their main access to health care is via the hospital emergency department (ED); they undergo repeated admissions but treatment is not really effective. In Toulouse, the number of homeless people who are ill is about 1000 and the estimated number of ED admissions is 1 or 2 per day. Suitable health facilities are available for these people but hospital staff are little aware of them. A health strategy involving both medical and social services thus needs to be developed and implemented. The objective of our study was to improve the follow up of destitute patients after discharge from ED by introducing a coordinated approach involving hospital staff and social workers within a network and by guaranteeing clear visibility of medical information. Programme In 2008, 90 patients were classified as destitute. We organised ad-hoc coordination tools, a central medical filing system, and regular multidisciplinary meetings between ED staff and the network. Assessment of the programme was based on: (1) a survey of ED staff9s awareness of the health facilities for the destitute, (2) a review of medical files, (3) monitoring of coordination tools, (4) compliance with the holding of multidisciplinary meetings. Results Between 2007 and 2008, we observed a 50% improvement in the awareness of ED staff of health facilities for the destitute. However, although two-thirds of the staff were better informed, they still did not make efficient use of the facilities available. Only 30% of the staff used the coordination tools, revealing room for much improvement. On the other hand, medical information was correctly centralised. Admission to ED was noted in 100% of patient medical files and 80% of the ED reports could be found in the file. The three planned multidisciplinary meetings devoted to file review took place and led to a joint medical-social health strategy for 90% of patients with repeated admissions. Cooperation between the ED and social facilities made for more fluid access to healthcare by these patients. After 1 year of network operation, 20% of destitute people were being looked after by an appropriate organism and were accessing healthcare via a general practitioner. Discussion and Conclusion Our study has highlighted the part that the hospital ED can play in the management of destitute homeless patients and the need to implement joint actions with social and other health facilities within a healthcare network. This ‘health network for the destitute’ provides expertise and support that can be immediately activated by ED staff. Use of the computerised personal medical file, when nationally available, should become routine when the homeless are admitted to the ED. Contexte et objectifs Les personnes en situation de grande precarite ont un etat de sante tres degrade. On note des deces precoces avec un differentiel d9esperance de vie allant de 30 a 35 ans si l9on compare a la population generale. Leur recours aux soins se fait essentiellement via les urgences hospitalieres par des passages iteratifs sans efficacite therapeutique. Des dispositif d9aval medico-sociaux adaptes existent pourtant mais ils sont peu connus des personnels hospitaliers. Il y a necessite de mettre en place une strategie de prise en charge medico-sociale concertee entre les differents partenaires concernes. Il y aurait environ 1000 personnes sur Toulouse malades et durablement a la rue. En 2006, nous avions estime le nombre de passage aux urgences de ces publics a environ 1 a 2 passages quotidiens. Notre etude a pour objectif d9ameliorer le suivi medico-social de ces patients apres leur passage aux urgences en installant une coordination entre hospitaliers et professionnels sanitaires et sociaux d9aval et en assurant une tracabilite des informations medicales dans le cadre d9une prise en charge en reseau. Programme 90 patients ont ete integres dans une filiere « grands precaires » en 2008. Des outils de liaison ad-hoc, une centralisation des donnees medicales et des reunions pluridisciplinaires entre les urgences et le reseau sont organises. Le suivi et la mesure des resultats se sont structures autour de quatre outils, une enquete par questionnaire sur les connaissances des dispositifs d9aval par le personnel des urgences, une revue des dossiers, le suivi des outils de coordination mis en place et la mesure de la perennite des reunions pluridisciplinaires. Resultats Entre 2007 et 2008, on note une amelioration de 50% de la connaissance des dispositifs d9aval par les personnels des urgences. Ainsi, 2/3 des personnels sont mieux informes mais ils ne savent pas encore utiliser les dispositifs de facon efficace. Seuls 30% des personnels utilisent les outils de liaison ce qui doit etre ameliore. La centralisation des donnees medicales est par contre correcte puisque 100% des triptyques temoignant du passage aux urgences et 80% des comptes-rendus d9hospitalisation sont presents dans le dossier medical du patient. Les trois reunions pluri-disciplinaires de revue de dossiers ont eu lieu et elles ont permis la mise en place d9une strategie medico-sociale concertee pour 90% des patients presentant des sejours iteratifs. Le decloisonnement entre structures hospitalieres et dispositifs adaptes a facilite la fluidite des parcours medico-sociaux des patients puisque sur un an, 20% des personnes integrees dans le reseau sont stabilises sur une structure d9aval adaptee et ont un recours aux soins via le dispositif medecin traitant. Conclusion Ce travail met en lumiere le role de veille apporte par les urgences hospitalieres pour ces patients et la necessaire complementarite a developper avec l9aval dans le cadre d9une prise en charge en reseau. Il s9agit d9une fonction d9expertise ou fonction support qui doit pouvoir etre sollicitee par les acteurs des urgences en temps reel sous forme d9une « equipe de liaison grands precaires ». Enfin, l9informatisation du dossier medical doit permettre son utilisation en routine lors des passages aux urgences.