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Case study: Transforming out-of-hospital care for people who are homeless

The challenge

At the end of hospitalisation, homeless patients are frequently discharged onto the streets without a home or shelter to go to.  As a consequence, homeless inpatients have five times the rate of emergency readmission and A&E visits after discharge from hospital, compared to deprived housed patients with a similar medical profile because they do not have a good place to recover.

Where there is limited access to out-of-hospital care, the default pathway is to ‘signpost’ patients who are homeless or at risk of homelessness to the local housing authority, often without arrangements in place for meeting wider care and support needs, and with no mandated timescale. Evidence suggests that this pathway is far from being implemented across England with only 39% of local authorities reporting that they have formal protocols in place for the admission and discharge of people who are homeless (Homeless Link, 2010) and where protocols are in place, Homeless Link report that these vary from area to area.

The research

Key facts

  • Chief Investigator: Dr Michelle Cornes, Senior Research Fellow, Kings College, London
  • The study ran from 9 August 2016 to 19 January 2018
  • 387 people were recruited to the study over 15 sites and over 52 discharge teams (The target was 378).
  • 13 social care organisations were also involved in delivering the study
  • Funded by the Health Services and Delivery Research Funding Programme

The study was designed to explore and establish some of the ways in which specialist integrated homeless health and care services (SIHHC) are being developed and implemented to facilitate hospital discharge in England.  It was designed and developed through a multidisciplinary research team with extensive experience of working collaboratively with homeless people and consisted of two work packages:

  1. to gain an informed understanding of the ways in which specialist integrated homeless health and care (SIHHC) services are being developed and implemented to facilitate hospital discharge in England and relatedly, the impact this is having on quality of care and organisational outcomes such as the prevention of readmission to hospital.

  2. a data and economic analysis working with twenty sites across England where homeless patients had been admitted to hospital. A cohort of homeless people who had used a specialist discharge scheme would be compared to a cohort of homeless people who had not used such provision, and comparing a patients hospitalisation history before and after engagement with specialist services.  

Lizzie Bizwell, Clinical Research Nurse at Northamptonshire Healthcare NHS Foundation Trust said:

"Although I'd worked within a multi-disciplinary team for many years, I'd not worked with so many different agencies across the health, social and charity sector. At first it was overwhelming and I was very grateful to the Pathway Team who told me about how patients experiencing homelessness were managed within the hospital and within social services post-discharge. In the community it was harder to establish relationships. It was a real learning curve”.

This film explains what the study was about, why it's important and what they discovered.

Making a difference

Homelessness places people at heightened risk of morbidity and mortality, with almost one in three deaths among people who were homeless and had experienced hospitalisation due to amenable causes. 

The study collected data on 3,882 individual homeless hospital admissions linked to 600 deaths.

  • Nearly one in three homeless deaths were due to causes amenable to timely and effective health care
  • Out-of-hospital care tailored to the needs of patients who are homeless is more effective and cost-effective than standard care.
  • NHS Trusts with specialist homeless discharge schemes had fewer Delayed Transfers of Care compared to those that relied on standard care.
  • There were 18% fewer A&E visits where Homeless Hospital Discharge (HHD) Protocols with a ‘step-down’ service compared to HHD schemes without ‘step-down’.

“Taking part in the study has been helpful because now I know I have the right to inform the hospital that I don’t have anywhere to go home to.”  Study participant


Recommendations

  1. Strengthen existing ‘HHD Protocols’ asking housing authorities to work to similar timescales as adult social care e.g. complete housing assessments within 72 hours to facilitate early discharge planning and improved monitoring of system flow.
  2. Integrate hospital-based specialist homeless health care teams (sometimes called Pathway teams) alongside existing multi-disciplinary discharge coordination services.
  3. Out-of-hospital care must be integrated so people can move seamlessly between different services, depending on changing needs.
  4. Provide alternative ‘housing-led’ (step-down) pathways out-of-hospital for people who need time for recovery and reablement but who cannot go home (they are homeless) but whose needs would be over-catered for in a care home.
    “I didn’t realise that I need to give them consent to talk to the housing authority to make them aware of my situation.” Study participant

 

Further reading

Housing and homelessness as a health crisis, 2019, The Lancet  

Causes of death amongst homeless people, a population based cross-sectional study of linked hospitalisation and mortality data in England, Wellcome Open Research 2019

Transforming out-of-hospital care for people who are homeless. Support Tool & Briefing Notes