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Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors Group 12 th International Street Medicine Symposium Geneva, 21 October 2016 Igor van Laere, MD PhD Michiel Vermaak, MD Marcel Slockers, MD

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Page 1: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Intellectual disability and mortality

among Dutch homeless people:

efforts and lessons of the

Netherlands Streetdoctors Group 12th International Street Medicine Symposium

Geneva, 21 October 2016

Igor van Laere, MD PhD

Michiel Vermaak, MD

Marcel Slockers, MD

Page 2: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Intellectual disability in

homeless people in the

Netherlands

Michiel Vermaak, MD

Michiel Vermaak, MD

Intellectual Disability Physician

Rotterdam, The Netherlands

Page 3: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Intellectual Disability Physician

3 year residency

“local authority physician experienced with people with problems…”

Multiple disability patients

with profound intellectual disability (ID) to mild ID

Page 4: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Consultations ID-Physican

▪ Early ID detection in populations in contact

with the Police, Justice and Mental

Healthcare Institutions

▪ To prepare ID prisoners to return to society

▪ Early ID detection in homeless people and

support Shelter staff

Page 5: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Medical questions pertinent to the homeless are:

•To what extent is cognitive impairment present?

•How will persistent deficits impact upon social

function and reintegration?

Intellectual disability and Street Medicine Practice

Page 6: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Intellectual Disability (ID) prevalence?

▪General Dutch population 0,7%

▪ Homeless populations ▪ Few studies available USA and UK

▪ Small groups

▪Cognitive impairment 12-40%

Page 7: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Study ID prevalence in homeless people in the Netherlands

▪ Amsterdam, Rotterdam, The Hague, Utrecht

▪ Barbara van Straaten, Plos One, January 2014

▪ Data collection July 2011-June 2012

▪ Hayes Ability Screening Index

▪ indication IQ<70

▪ N = 513

Page 8: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

29,5% suspected ID

▪ Homeless people with ID are a vulnerable subgroup in the homeless population

▪Suspected ID (IQ < 70) were more likely male and

in the lowest education category and had more

general psychological distress, somatization,

depression and substance dependence. Van Straaten et al. PlosOne, 2014

Page 9: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Havenzicht Shelter Rotterdam

• 42 shelter beds

• 20 nursing beds

• 17 residential

apartments

• 297 new facility users in

2015

Page 10: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

ID practice results 2015

▪ New registrations N=297

▪ SCIL tests N=145 (49%)

▪ Male N =134 (92%)

▪ Average age 39 years (23 - 64 years)

▪ Average Scil score 17,6

▪ Score <19 N=82 (57%)

▪ Validated Mild ID (<70!) N=37-55 (26-38%)

Page 11: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Shelter ID-practice

▪ In 2015 the SCIL test introduced

▪ Social workers trained

▪ All shelter users invited for a test

▪ ID Physician consultation available

▪ In depth IQ-test: Esseon-R or Vineland-Z

Page 12: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Tools

Scil

Page 13: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Tools

Moca

Page 14: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Tools

www.mocatest.org

Page 15: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors
Page 16: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

ID-practice lessons

▪ SCIL test has been integrated in daily shelter routine

▪ Increased ID awareness among shelter staff

▪ Early detection of suspected ID

▪ Active involvement of ID physician at the shelter

▪ ID adjusted approach and communication by shelter staff

▪ Less violence and suspensions witnessed

▪ Implicatons for case management

Page 17: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Article 12

The right to aid in distresswhoever is in distress, and is not in a position to look after themselves, has the right to

help and assistance and also to benefit from the indispensable means for living a dignified human life.

Page 18: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Twitter

@ArtsVG

uuueeehhhm … an Intellectual Disability Physician?

What do you see?

Page 19: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Mortality among the homeless in

the Netherlands

Not an easy life; not an easy

death?

Marcel Slockers

General practioner and streetdoctor

Page 20: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

▪ prevalence mortality

▪ result improved living conditions since 2006

▪ reduction of deaths by injuries

▪ palliative care in a homeless nursery shelter

▪ conclusions

Mortality among the homeless in

the Netherlands

Not an easy life; not an easy

death?

Page 21: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

1940 bombing Rotterdam

Page 22: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

homeless adults 2001-2010

•the cohort of homeless adults in 2001

consisted of 1870 men and 260 women

•2130 persons

•with a mean age of 40.3 years

•during the 10-year of follow-up

265 persons (232 males and 33 females)

died

Page 23: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

10 year follow -up

•Register-based 10-year follow-up study of

homeless in Rotterdam, the Netherlands.

•The Participants are homeless adults

(18+),

•who visited one or more services for

homeless people Rotterdam in 2001

Page 24: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Difference in remaining life

expectancy

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Page 26: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Social relief package for Dutch

homeless people since 2006

Social education training and rehabilitation

Individual or clustered supported housing

Healthcare support (mental + addictions)

Daytime activities / job guidance

No arrangements for physical healthcare?

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No changes in mortality rate since

2006

Page 28: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

success since 2006

•the safety index of the city rapidly improved,

reflecting reductions in violent crimes

•reduction of street use of illegal drugs, and

feelings of unsafety

•improved quality of life of all Rotterdam

citizens, including the (former) homeless

•75% decrease in tuberculosis incidence

among homeless persons has been observed

Page 29: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Rotterdam policy and homeless mortality

- In a homeless cohort, 5 years of local policy

efforts improved their living conditions

- mortality rates did not change

- Beneficial effects on causes of death

- Incomplete reach of our cohort

- Detection of risk factors and profiles

Page 30: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Proportion of deaths by cause of death in a dutch

homeless cohorrt 2001-2010

Page 31: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Homeless deaths by injury

▪ 13% intentional; murder, suicide

▪ 7% unintentional; traffic trauma

▪ 6% accidental poisoning, drug overdose

Page 32: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Both sexes combined.

Hazard Ratio. 2006-2010

vs 2001-2005 (CI)

P-

value

Injury 0.68 (0.41-1.12) 0.68

Cancer 0.51 (0.15-1.76) 0.50

Cardiovascular diseases 1.39 (0.81-2.39) 0.23

Infectious diseases 0.51 (0.15-1.76) 0.28

Respiratory diseases 0.84 (0.30-2.32) 0.73

Gastrointestinal disease 2.17 (0.78-6.07) 0.12

Psychiatric disorders 2.44 (0.66-9.09) 0.16

Other diseases 0.48 (0.24-0.99) 0.04*

Intentional injury 0.45 (0.20-0.98) 0.03*

Accidental poisoning 0.84 (0.32-2.19) 0.83

Other accidents 1.10 (0.42-2.90) 0.84

Mortality in homeless cohort after (2006-2010)vs

before (2001-2005) implenting social policy

measures

Page 33: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Palliative care for homeless people

extremely difficult

-Multiple admissions at multiple settings

-Frail physical condition

-Psychiatric disorders

-Substance abuse

-Intellectual disability

-Polypharmacy (van Laere et al, BMC HSR 2009; Slockers et al, Neth J Med 2015)

Page 34: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Shelter based convalescence and

palliative care

- Experienced team, nurses

- Complex health problems

- Palliative care consultation team

- Palliative sedation extremely difficult in

poly drug (opiate) users

Page 35: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Mortality lessons not an easy life not an easy death

Premature death females 16 years, males 14 years death by injury not 5% but 26%

After social relief investment injury-related deaths largely dropped hazard ratio 0,45 Uneasy life and death Palliative care team is highly needed Palliative sedation is a big challenge

Page 36: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Netherlands Streetdoctors Group

Activities

▪ Igor van Laere MD PhD

▪ The results and effects of a national

network of homeless healthcare workers

▪ www.doctorsforhomeless.org

http://www.doctorsforhomeless.org/
Page 37: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Operation Safety Net, Pittsburgh 2007

Page 38: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

9th International street medicine symposium Boston USA 25 October 2013

Page 39: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Netherlands Streetdoctors Group (NSG)

▪ Founded June 2014

▪ Executive part of the Doctors for Homeless

Foundation Amsterdam, est. 2008

▪ Point of contact and advice

▪ Sharing knowledge and experience

▪ Promoting education and research

▪ Promoting political awareness

▪ www.doctorsforhomeless.org

http://www.doctorsforhomeless.org/
Page 40: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

10th International Street Medicine Symposium Dublin Ireland, October 2014

Page 41: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors
Page 42: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

NSG results June 2014 – Oct 2016

NSG activities June 2014- Oct 2016 Number

SYMPOSIUMS ORGANIZED Netherlands Streetdoctors Symposium

3

RESEARCH CONDUCTED Landscape national homeless healthcare

Alarm growing uninsured homeless

2

PUBLICATIONS Papers in medical journals, text book, reports,

columns and poster

20

EDUCATION Presentations at symposiums, workshops,

lectures

44

MEDIA Interviews TV, newspapers, magazines

12

POLITICS Chamber letters in National Parliament

Visits Ministry of Health

10

Page 43: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Develop and implement a model of social medical care for homeless people ▪ Middle sized city for pilot

▪ Stakeholders consent and cooperation

▪ Model building stones:

▪ Care team

▪ Care performance

▪ Care beyond office hours and in crisis

▪ Care and quality

▪ Input expertise (inter)national network

Page 44: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Conclusions

▪ High prevalence of intellectual disability and premature

mortality among the homeless in the Netherlands

▪ A national network of outreach street medicine

professionals has joined forces

▪ High output of sharing street medicine lessons

▪ High reach of stakeholders and policy makers

▪ Pilot to develop and implement a social medical care

model for the homeless in progress

Page 45: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Recommendations

▪ Introduce systematic ID-testing

▪ Focus on factors / profiles increased mortality risk

▪ Build and strengthen (inter)national networks of

street medicine professionals

▪ Start counting and collect simple data

▪ Promote education and research

▪ Reach out to policy makers to make a difference

Page 46: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

Centre de l’Esperance Geneve, Switzerland

Page 47: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

See you in Rotterdam in 2018

Page 48: Intellectual disability and mortality among Dutch …...2016/10/21  · Intellectual disability and mortality among Dutch homeless people: efforts and lessons of the Netherlands Streetdoctors

contact

▪Igor van Laere [email protected]

▪Michiel Vermaak [email protected]

▪Marcel Slokcers [email protected]

www.doctorsforhomeless.org

mailto:[email protected]
mailto:[email protected]
mailto:[email protected]
http://www.doctorsforhomeless.org/

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