Published: 16 January 2023
Emergency readmission five times more likely for homeless patients
Homeless patients are ten times more likely to die early than the rest of the population, with many deaths being from preventable causes. Despite having poorer health and more complex needs, homeless people use few planned healthcare services but make more regular and repeated visits to emergency departments.
Previously, few intermediate care services existed for homeless people leaving hospital and up to 70% were discharged to immediately sleep rough on the street. With little access to community healthcare, they are five times more likely to be readmitted as an emergency than housed people.
In 2013, 52 homeless community organisations across England received £10 million government funding to develop supportive specialist discharge schemes for homeless people when they leave hospital. The schemes provide a link in care between hospitals and the community (“intermediate step-down care”). This could, for example, help people find short-term accommodation while they recovered from illness or surgery and thereby reduce the likelihood of readmission to hospital.
With £800,000 funding from the NIHR Health and Social Care Delivery Research Programme, a team led by Professor Michelle Cornes from the University of Salford, evaluated how effective those schemes were.
Reducing emergency hospital readmissions
Between 2015 and 2019, the research team studied data from 17 hospitals offering specialist homeless discharge schemes. These schemes aimed to help homeless people find housing or focused on improving care and reducing early or late hospital discharges. Some schemes offered a combination of both services.
Over a 3-year period, and with input from people with lived experience of homelessness, they collected information about more than 3,800 homeless people’s hospital admissions. This data was compared with equivalent information about housed people living in the most deprived areas of England.
Published in the journal Health Services and Delivery Research, their results showed that women were nine times and men seven times more likely to die than the general population. Many of the deaths were from cancer, digestive diseases and heart disease that may have been treatable at an earlier stage.
"Nearly one in three deaths might have been prevented with better access to healthcare. There is a pressing need for intermediate healthcare for homeless people to allow them to recover once any emergency or acute illness has been dealt with."
Professor Michelle Cornes
The team’s evidence, also published in Wellcome Open Research, informed a King’s Fund report on Delivering health and care for people who sleep rough, and was cited in a discussion about reduced life expectancy for homeless people in BMJ Opinion.
Patients reliant on drugs or alcohol reported feeling stigmatised and were more likely to be prematurely discharged from hospital. The specialist discharge schemes created a pathway out of hospital which reduced stigma and led to safer transfer of patients’ care into the community. “The step-down schemes work to free up hospital beds while ensuring people have somewhere safe to stay while their housing and other issues are sorted out,” Professor Cornes said.
The results also highlighted how step-down care was better for patients and NHS resources. Visits to accident and emergency departments were nearly one-fifth lower among homeless patients who were discharged to a step-down service compared with those who were not. Their results informed changes to the national hospital discharge guidance, which is now more inclusive of the needs of patients who are homeless.
A cost-effective approach to improving care
The team’s evaluation of the schemes’ cost-effectiveness, published in the journal Health and Social Care in the Community, found that step-down care costs were similar to those of bed-based care in hospital, but also secured better ongoing health for homeless people. Professor Cornes said: “Our research identified examples of innovative partnerships between local health, housing and homelessness services that saved the NHS money in the long run.”
The team also published a “support tool” of the factors decision-makers should consider when planning safe transfer of homeless patients’ healthcare from hospitals into the community. The tool is now embedded in national hospital discharge guidance for local government authorities and NHS England, ensuring that discharge practices are improved.
The study’s evidence was also used to advise government policymakers on how to strengthen safeguarding for homeless patients. This led to improved information and training for NHS staff about homeless health and updated NHS England guidance confirming that it is not safe practice to discharge patients to the street.
In 2020, the government allocated £16 million funding to 17 local authorities to implement the study’s findings and put the models of care into practice. The following year, Professor Cornes and her team began a 2-year evaluation of the models’ success, funded by the Department of Health and Social Care.
While this work was under way, NICE issued a new guideline on Integrated health and social care for people experiencing homelessness that reflected the NIHR-funded study’s findings. The guideline confirms that more targeted health and social care approaches should be in place. It gives recommendations for commissioners, healthcare providers and local authorities to support the safe discharge of homeless patients, giving those patients better opportunities to recover from illness.
The study was funded by NIHR’s Health and Social Care Delivery Research Programme.
More information about the study is available on the NIHR’s Funding & Awards website.
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