Bevan Healthcare's York Street Health Practice is the hub for the small team who bring healthcare to vulnerable people across the city.
GPs, a paramedic, two registered nurses and an occupational therapist are caring for rough sleepers and people in temporary accommodation who are homeless or seeking asylum.
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Throughout Covid they have increased outreach work to ensure the safety of patients, many with complex mental and health and physical problems.
The team helped track down many of the rough sleepers in Leeds at the start of the pandemic before placing them in emergency accommodation including hostels and hotels.
The team has dealt with 282 homeless people with almost 900 face to face consultations since the first lockdown in March.
Bevan Healthcare, which works alongside partners Leeds Clinical Commissioning Group and Leeds City Council, practises what it calls inclusion health to focus on the most vulnerable members of society.
It tries to address their needs in a holistic way by taking account of mental health and social factors rather than just dealing with obvious physical illnesses.
York Street Healthcare nurse consultant Mat Sidebottom is leading its healthcare Covid response for the city's homeless and asylum seekers.
Mat said Covid has given his team a unique opportunity to deal with and treat many homeless people for a sustained period while they are in emergency accommodation.
Mat said: "For many organisations Covid has hindered their operations, but it has given us a fantastic opportunity to engage with people like never before.
"We have worked with the hepatitis team at Leeds hospitals to get more people treated for Hepatitis C.
"We have managed to test people we would have struggled to engage with previously.
"The homeless population has been as worried as everybody else about Covid. Through that concern they have been more willing to engage with us."
Mat said his team will be working with Leeds City Council and Leeds Clinical Commissioning Group to try and ensure long term positive health and housing outcomes for as many homeless people as they possibly can.
The team's occupational therapist is Beck Skelton, who takes a 'whole person' approach to both mental and physical health and wellbeing.
Mat said: "She has given a musical instrument to a homeless musician to help with his mental health, and handed out personalised activity packs and used occupation and activity in a number of creative ways to help address the emotional and mental health needs of such a vulnerable group of people."
Qualified paramedic Dominic Maddocks works full-time with the homeless population of Leeds.
Mat said: "Since the start of the pandemic, Dom has been incredibly flexible in how and where he is able to interact with his patients, ensuring that those who are at highest risk from Covid complications are monitored regularly and have the care they need.
"Becky Wellington is another new addition to the team and as an advanced nurse practitioner with a mental health nurse background, she brings a wealth of experience to the team. She is able to address a host of physical and mental health needs."
Mat said: "Bevan Healthcare is founded on the principle that everyone deserves excellent person-centred care.
"With the support of the Leeds Clinical Commissioning Group and Leeds City Council, we have been able to use our experienced team of professionals in creative ways to address the needs of the most vulnerable through what has been a difficult time for all of us and has likely shaped services for the homeless and asylum seekers in Leeds for years to come."
The YEP has previously reported that health chiefs at Leeds Clinical Commissioning Group have published what has been described as one of their most “innovative and dynamic” plans to tackle the issue of health inequality in Leeds once and for all and help close the gap in health outcomes between rich and poor.
In the CCG’s annual review, chief executive Tim Ryley, together with Jason Broch, clinical chair, said the pandemic’s impact will be “far reaching and long lasting”, affecting people’s physical health, mental welling, livelihoods and communities - with those living in areas of deprivation among the hardest hit.
“The economic decline and social disruption resulting from the pandemic will almost certainly harm health and widen health inequalities”, they said.
The CCG's new health inequalities framework will now be a major factor in the work to mitigate the effects of the pandemic.
The ambitious blueprint for action has shaken up the way the CCG has traditionally run health services and gives more power - and funding - to communities to tackle issues head on.