Question

What to do with patients that are not followed up in a safe and sustainable way, people without an official address and / or persons who refuse any kind of care?

Problem description

Our team has already to deal with requests to follow up patients with an irregular administrative situation (no official address) or people who have depleted their network in such a way that a referral to our team is seen as their last chance.  Normally we refuse these type of demands: you can’t co-operate with a non-existent network or a network that gives up the patient. Support in a home situation can never be started up in an optimal manner when the patient doesn’t have a home (= basic need)

Impact - effect

An access is denied to these patients, even though care is really necessary.  Less professional care is developed to cope with these situations, in terms of time and material resources.  By consequence further marginalisation is threatening these persons, they will become too much a burden on the poor professional network left. In the long term this could lead to problems in the relationship between professionals

To do

To do 1) think about an adjustment of our target group, making it possible to target persons without an official address, and  / or resistant to care, and/or with a poor or non-existent network, develop a specific approach for care avoiders

To do 2): develop specific co-operations more profoundly: with crisis centers, shelters,…

To do 3): training in specific approaches: how to approach a person without compromising an existent but often fragile relation (professional, family).   How to create trust and a bond by focussing in first instance on basic needs: housing, food,…

To do 4) creating an IT-tool, as a framework for every involved professional, that is flexible enough for these type of patients

Theme

Starting up and further development/deployment of mobile teams

Topic

critical success factors for starting up and further development/deployment

Reference -  contact

Sophie Chantry

Mobile team

2B

Project

Hainaut Occidental

Intership abroad - place

Lausanne (SIM, CMT)

Date

January 2013