1. Felicity Reynolds
CEO, Mercy Foundation &
Chair,Australian Common Ground Alliance

2.  Some background about terminology.
 A bit about Hwang’s US research into brain
injury and chronic homelessness.
 What is theVulnerability Index (VI)?
 What has theVI told us about brain injury and
chronically homeless people in Australia?
 What might all this mean?

3.  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 the
likely method by which the injury was ‘acquired’.
 It speaks to the likelihood of a traumatic and, possibly
violent, childhood, as well as theTBIs that can be acquired
when you have to cope on the streets and live in unsafe
places, the violent experiences of prisons and other
institutions and, of course, the experiences of being
regularly intoxicated and falling down a lot.These are all
ways in which someone might do permanent damage to
their brain.

4.  Hwang (2007) – a study onTBI with 1200 homeless
people.
 Summary results:
 Lifetime prevalence ofTBI in a representative sample of homeless
people is more than 5 times greater than in the U.S. general
population
 TBI prevalence among homeless people is within the range reported
among prison inmates.
 FirstTBI usually occured prior to the first episode of homelessness
 History ofTBI strongly associated with wide array of adverse health
outcomes.
 Cognitive consequences ofTBI may increase the risk of subsequent
mental health, alcohol, and drug problems.
 However, pre-existing mental health, alcohol, and drug problems may
increase the risk of experiencingTBI.

5.  Clinicians should routinely screen homeless patients for history ofTBI.
 TBI should be considered a possible cause of neuro-psychological
dysfunction and behavioral problems.
 Further efforts should be directed at the management ofTBI-related
problems such as impulsive behavior, and the treatment of co-occurring
alcohol or substance abuse.
 Persons with brain injuries may have attention deficits, making it difficult
for them to focus on tasks and understand, remember, or respond to
directions.
 These individuals may need more time to follow instructions; slowness
should not be misinterpreted as a lack of effort or cooperation.
 TBI-related brain dysfunction can predispose to irritability or impulsivity
that should be understood in the context of the person’s previous injury.

6.  Many of you work in organisations that see homeless
people daily and you know the context.The following
is about a methodology for knowing, doing
something and measuring outcomes.
 What is theVulnerability Index?
 Some of you already know (and have been directly
involved here in Sydney).
 For those that don’t....it is not an ‘assessment tool’, it
is a practice instrument and methodology for a local
campaign to locate chronically homeless people,
complete aVI survey to better understand their health
and housing needs and then to work with them to
achieve a housing goal (PSH – if relevant).

7.  Huge coincidence! Hwang was actually the
co-author of research (done in the 1990s with
Dr Jim O’Connell, on which theVI is based).
That particular research was broader and
looked at all the health vulnerabilities of
chronically homeless people.
 They found 8 vulnerability factors that put
people who were homeless (compared to
people who were housed) at greater risk of
death.

8. 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 prior
three months
 Three or more ER or hospitalisations in prior year
 Tri-morbid (mentally ill+ abusing substances+
medical problem)

9.  An additional 3 vulnerability factors:
 Alcohol everyday in past 30
 HIV+/AIDS
 Injection Drug Use
Quick description of methodology for Registry
Weeks and next slide – Registry Week’s with
VI in Australia, since 2010.

10. 425
56
148
463
321
109
321
1680 people surveyed as at August 2012
158

12.  76% male
 22% female
 Most of the population surveyed were
between 36 and 55 (54%) years old
 23% identified as Aboriginal or Torres Strait
islander.
(Note these statistics don’t include Perth)

13.  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) had
not been housed at all in the past three years
 26% had been housed/re-housed 3 times or
more
 6% had been housed/re-housed 10 times or
more.
(Note these statistics don’t include Perth)

14. Homeless history
Average age and time homeless - by region
6 10 9 15
7
6
0
10
20
30
40
50
60
Brisbane Sydney Melbourne Townsville Hobart Western Sydney
Average age Average years homeless
44 45 44 48 38 40
Sample size = 1522

15. Vulnerability
Australia-wide by region
Brisbane Townsville Sydney
Western
Sydney Melbourne Hobart Total Percentage
Sample size 425 56 463 148 321 109 1522 100%
Number of
vulnerable 295 36 294 67 204 70 966 63%
Perth (August 2012)Total sample size = 158
Number ofVulnerable = 93 (59%)

16.  61% reported a mental health condition
 51% reported having received treatment for a
MH condition
 73% reported drug/alcohol abuse
 46% reported having received treatment for
drug/alcohol abuse
 51% had been the victim of a violent attack
 24% reported a disability that limited their
mobility

17.  29% reported a brain injury or
head trauma.
 Yes....almost a third of all respondents (with
significant histories of homelessness) SELF –
reported a brain injury or head trauma.

18.  So, perhaps those chronically homeless
people who are ‘treatment resistant’ or ‘non-
compliant’ might actually not be able to
remember appointments too well.They may
have impulse control problems.
 Theymay need to be supported in a different
way.They may need some extra help to
remember things (as just one example).
 If suspected, a neuro-cognitive assessment
should be arranged.

19.  All chronically homeless people need housing to
solve their homelessness and some may also
need ongoing support to sustain housing (PSH).
 This is KNOWN (not guessing) to include almost
a THIRD of all chronically homeless people who
may have problems caused by aTBI - and require
permanent (not transitional) support to sustain
housing. (Additional evidence for this need is their
current state of long term homelessness.)

20.  Permanent Supportive Housing is the only
answer for people with significantTBI and chronic
history of homelessness.
 Through theVI, we have gained a better
understanding of how many (and who they are –
and some are now in PSH) in the chronically
homeless population may need this type of
ongoing support to sustain housing.
 In fact, there could also be a number of this
population who may require significant (including
24 hour) care (but more specialist assessment
information would be needed).