Housing, Care and Support

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ISSN 1460-8790Volume 22 Number 1 2019

Housing Care and SupportA journal on policy research and practice

wwwemeraldinsightcomloihcs

Volume 22 Number 1 2019

Housing Care and SupportA journal on policy research and practice

This special issue was produced in partnership with the Housing Quality Network (HQN) HQN is a

membership organisation providing high-quality advice tailored support and training to housing associations

councils ALMOs and other housing providers

Number 1

Situating and understanding hospital discharge arrangements for homeless peopleGuest Editors Martin Whiteford and Michelle Cornes

1 Guest editorial

4 Hospital discharge planning for Canadians experiencing homelessnessKristy Buccieri Abram Oudshoorn Tyler Frederick Rebecca Schiff Alex Abramovich Stephen Gaetz and Cheryl Forchuk

15 The GP role in improving outcomes for homeless inpatientsZana Khan Philip Haine and Samantha Dorney-Smith

27 Hospital collaboration with a Housing First program to improve health outcomes for people experiencing homelessnessLisa Wood Nicholas JR Wood Shannen Vallesi Amanda Stafford Andrew Davies and Craig Cumming

40 Homeless medical respite service provision in the UKSamantha Dorney-Smith Emma Thomson Nigel Hewett Stan Burridge and Zana Khan

54 The Cottage providing medical respite care in a home-like environment for people experiencing homelessnessAngela Gazey Shannen Vallesi Karen Martin Craig Cumming and Lisa Wood

65 Establishing a hospital healthcare team in a District General Hospital ndash transforming a model into a realityRose Isabella Glennerster and Katie Sales

77 Improving outcomes for homeless inpatients in mental healthZana Khan Sophie Koehne Philip Haine and Samantha Dorney-Smith

ISBN 978-1-83867-211-9

Situating and understanding hospital discharge

arrangements for homeless people

Guest Editors Martin Whiteford and Michelle Cornes

Martin Whiteford and Michelle Cornes

Situating and understanding hospital discharge arrangements for homeless people

The importance of specialist hospital discharge arrangements for homeless people has beenwidely documented (see eg Whiteford and Simpson 2015 Albanese et al 2016 Corneset al 2018) Much of the work that has emerged to date has been dispersed across a broadrange of disciplinary fields (eg emergency medicine healthcare administration public healthand housing studies) and in consequence of this there has been a tendency to speak to discreteaudiences rather than say an explicit concern with fostering inter-disciplinary dialogue In theextant literature four main features stand out The first is the tendency to provide descriptiverather interpretative accounts of the role of specialist homeless healthcare teams The role ofclinicians features prominently in such accounts while the experiences and reflections ofhomeless patients have often been relegated to the margins The second feature is the overtfocus on hospital administrative data In such analyses hospital episode statistics (eg EDpresentations impatient admissions and emergency readmissions) are commonly used toillustrate the rates of healthcare utilisation among people who are homeless or at risk ofhomelessness The third characteristic is the cost of hospital services for homeless patients andor the effectiveness of community-based healthcare interventions (McCormick andWhite 2016)The fourth tendency is to examine medical respite care for homeless people (Doran et al 2013)Research in this area has consistently demonstrated the efficacy of medical respite for homelesspeople in terms of contributing to decreases in ED presentations as well as reductions in thenumber of unplanned inpatient days followed up by a period of recuperative care

Existing scholarship devoted to the issue of hospital discharge protocols and policies forhomeless people have tended to start from the position that people who are homeless oftenexperience poor hospital discharge arrangements (Blackburn et al 2017) Strong andcontinuous evidence has shown how unsafe discharge arrangements are costly at bothindividual and societal levels with many people who are homeless entering a cycle of hospitalreadmission which in turn serves to compound existing health inequalities Among practitionersand scholars there is a discernible (and oftentimes explicit) critique of ldquopatient dumpingrdquo ndash aphenomenon in which homeless patients are discharged not to temporary housing but to thestreets Indeed the failure to discharge homeless patients into appropriate accommodation isunderstood to lead to a cycle of poor health and episodic healthcare use This lack ofcoordinated care inevitably leads to emergency readmission and prolonged lengths of hospitalstay These factors by degrees place a significant burden on over-stretched and under-fundedhealthcare systems Framed in this way poor discharge practices and policies are commonlyconsidered to be a moral and economic abomination

Viewed from the other end of the telescope specialist hospital discharge arrangements forhomeless people are understood to be predicated on two overarching and intertwined concernsfirst a concern with turning off the spigot of ldquopatient dumpingrdquo and second a concern withactively engaging with the often complex and seemingly intractable housing and health needs ofpeople affected by homelessness These twin aims are it is argued best achieved throughensuring that housing and health needs are considered at the point of admission duringtreatment and post-discharge Together these concerns and aims have created a commonnarrative and policy agenda in the four main countries in the Anglosphere (ie the USA CanadaAustralia and the UK)

How did this happen To understand and contextualise the growing interest in homeless hospitaldischarge we must place it in the context of the paradigmatic shift towards auditing in healthcare

Martin Whiteford is based atthe Health Services ResearchUniversity of LiverpoolLiverpool UKMichelle Cornes is based at theNIHR Health and Social CareWorkforce Research UnitKings College LondonLondon UK

DOI 101108HCS-03-2019-030 VOL 22 NO 1 2019 pp 1-3 copy Emerald Publishing Limited ISSN 1460-8790 j HOUSING CARE AND SUPPORT j PAGE 1

Guest editorial

rising levels of homelessness and associated patient complexity and a desire among clinicians andpractitioners to achieve the appropriate balance between organisational interventions and acompassionate orientation towards the care and support needs of vulnerably patients such aspeople who are homeless This impulse to practise ethically and in a compassionate setting is inmany important respects the signal feature of specialist hospital discharge arrangements forhomeless people Such specialist initiatives and homeless health and care provision moregenerally can be better understood as a repudiation of routine forms of care

The issue of specialist hospital discharge arrangements for homeless people shows how policyideas travel and transform local practices This internationalisation of homeless healthcare hasbeen driven in significant part by a network of practitioners and scholars committed to sharinglearning and best practice across national borders and clinical frontiers This internationalexchange of ideas is perhaps been exemplified by the UK Faculty for Homeless and InclusionHealthrsquos annual symposium on health homelessness and multiple exclusion The Boston HealthCare for the Homeless Programme and Health Care for the Homeless Pittsburgh can and shouldrightfully be seen as the progenitors of this movement by virtue of their ground-breaking work andlongstanding commitment to ensuring that homeless people have access to comprehensivehealthcare The field of homeless healthcare continues to evolve and it has now developed itsown nomenclature under the conceptual and clinical scaffolding of ldquoinclusion healthrdquo (Pathway2018 for a detailed exposition) Underlying this change in language and shift in perspective is aclear recognition that to take just a few examples asylum seekers migrants sex workers andGypsies and Travellers also face significant barriers to effective healthcare Put crudely the centreof gravity has shifted in small but perceptible ways from the USA to the UK Central to this shifthas been the work of the Pathway charity In practice terms Pathway embodies a simple andsuccessful model of enhanced care coordination for homeless patients admitted to hospital Itoperates across ten hospitals in England and has an international outpost in Perth WesternAustralia Pathway can thus be understood as a symbol as well as a reality of a different type ofhealthcare engagement with homeless people and it is as a reality that it has had its mostprofound impact

In the UK particularly in the English context knowledge and understanding of the importance ofthe discharge needs of homeless patients has quickly metastasised through a series of nationaland local evaluations (see Homeless Link 2015 for exegesis) government-sponsored fundingstreams (DoH 2013) and programmes of academic inquiry[1] Whilst it would be misleading tosuggest that full nationwide coverage has been achieved it is certainly the case that dischargeplanning for people who are homeless has moved from the periphery to the mainstream in policyformation and practice delivery in England if not necessarily across the whole of the UK (Whitefordand Simpson 2016) Visible traces of this can be seen in both the governmentrsquos rough sleepingstrategy (MHCLG 2018) and the NHS long-term plan At the same time specialist homelesshospital discharge schemes have been emasculated by the UK Governmentrsquos ongoing austeritydrive This issue in and of itself deserves further attention

This special issue of Housing Care and Support brings together seven individual papers whicharticulate and analyse different facets of hospital discharge arrangements for homeless peopleThe collection opens with an examination of hospital discharge planning for Canadiansexperiencing homelessness (Buccieri et al) This is then followed by an exploration of the GP rolein improving outcomes for homeless patients (Khan et al) This then gives way to a criticalappraisal of a collaboration between an inner-city hospital specialist homeless GP service and aHousing First imitative in Perth Australia (Woods et al) The focus then shifts to a review ofmedical respite care in the UK (Dorney-Smith et al) before giving way to a companion piece ofsorts which provides a detailed discussion of a medical respite care facility in Melbourne Australia(Gazey et al) Following this is a fairly expansive and in many ways a deeply personal account ofthe difficulties of establishing a homeless healthcare team in a district hospital in the south-west ofEngland (Glennerster and Sales) The collection concludes with a close appraisal of the firstclinically-led interprofessional Pathway homeless team in a mental health trust in England (Khanet al) Taken together these papers all argue persuasively and passionately for the importance ofcoordinated and comprehensive discharge planning for people who are homeless and in doingso offer important and opportune insights

PAGE 2 j HOUSING CARE AND SUPPORT j VOL 22 NO 1 2019

Note

1 wwwkclacuksspppolicy-institutescwrureshrphrp-studieshospitaldischargeaspx

References

Albanese F Hurcome R and Mathie H (2016) ldquoTowards an integrated approach to homeless hospitaldischarge an evaluation of different typologies across Englandrdquo Journal of Integrated Care Vol 24 No 1pp 4-14

Blackburn R Hayward A Cornes M McKee M Lewer D Whiteford M Menezes D Luchenski SStory A Denaxas S Tinelli M Wurie F Byng R Clark M Fuller J Gabbay M Hewett N Kilmister AManthorpe J Neale J and Aldridge R (2017) ldquoOutcomes of specialist discharge coordination andintermediate care schemes for patients who are homeless analysis protocol for a population-based historicalcohortrdquo BMJ Open Vol 7 No 12 available at httpdxdoiorg101136bmjopen-2017-019282

Cornes M Whiteford M Manthorpe J Byng R Hewett N Clark M Kilmister A Fuller J Aldridge Rand Tinelli M (2018) ldquoImproving hospital discharge arrangements for people who are homelessa realist synthesis of the intermediate care literaturerdquo Health and Social Care in the Community Vol 26 No 3pp e345-59

Department of Health (2013) Homeless Hospital Discharge Fund 2013ndash14 Department of Health London

Doran KM Ragins KT Gross CP and Zerger S (2013) ldquoMedical respite programs for homeless patientsa systematic reviewrdquo Journal of Health Care for the Poor and Undeserved Vol 24 No 2 pp 499-524

Homeless Link (2015) Evaluation of the Hospital Discharge Fund Homeless Link London

McCormick B and White J (2016) ldquoHospital care and costs of homeless peoplerdquo Clinical Medicine Vol 16No 6 pp 506-10

Pathway (2018) Homeless and Inclusion Health Standards for Commissioners and Service ProvidersPathway London

Whiteford M and Simpson G (2016) ldquolsquoThere is still a perception that homelessness is a housing problemrsquodevolution homelessness and health in the UKrdquo Housing Care and Support Vol 19 No 2 pp 33-44

Whiteford M and Simpson G (2015) ldquoWho is left standing when the tide retreats Negotiating hospitaldischarge and pathways of care for homeless peoplerdquo Housing Care and Support Vol 18 Nos 34pp 125-35

VOL 22 NO 1 2019 j HOUSING CARE AND SUPPORT j PAGE 3

Hospital discharge planning for Canadiansexperiencing homelessness

Kristy Buccieri Abram Oudshoorn Tyler Frederick Rebecca Schiff Alex AbramovichStephen Gaetz and Cheryl Forchuk

Abstract

Purpose ndash People experiencing homelessness are high-users of hospital care in Canada To betterunderstand the scope of the issue and how these patients are discharged from hospital a national survey ofkey stakeholders was conducted in 2017 The paper aims to discuss this issueDesignmethodologyapproach ndash The CanadianObservatory onHomelessness distributed an online surveyto their network of members through e-mail and social media A sample of 660 stakeholders completed themixed-methods survey including those in health care non-profit government law enforcement and academiaFindings ndash Results indicate that hospitals and homelessness sector agencies often struggle to coordinatecare The result is that these patients are usually discharged to the streets or shelters and not into housing orhousing with supports The health care and homelessness sectors in Canada are currently structured in away that hinders collaborative transfers of patient care The three primary and inter-related gaps raised bysurvey participants were communication privacy and systems pressuresResearch limitationsimplications ndash The findings are limited to those who voluntarily completed thesurvey and may indicate self-selection bias Results are limited to professional stakeholders and do not reflectpatient viewsPractical implications ndash Identifying systems gaps from the perspective of those who work within healthcare and homelessness sectors is important for supporting system reformsOriginalityvalue ndash This survey was the first to collect nationwide stakeholder data on homelessness andhospital discharge in Canada The findings help inform policy recommendations for more effective systemsalignment within Canada and internationally

Keywords Canada Privacy Hospital Patients Homelessness Systems alignment

Paper type Research paper

Homelessness is an experience that intersects with multiple social determinants of health suchas inequitable income distribution unemployment food insecurity inadequate housing disabilityand social exclusion (Mikkonen and Raphael 2010) Yet despite health inequities manyindividuals who experience homelessness do not have a regular physician and instead rely onhospitals for care Researchers have found high rates of hospital use among individualsexperiencing homelessness (Tadros et al 2016) most commonly for injuries resulting in sprainsstrains contusions abrasions and burns (Mackelprang et al 2014) Canadian studies haverecorded high percentages of homeless individuals who report at least one hospital visit in thepreceding year with figures as high as 77 percent (Hwang and Henderson 2010) This indicatesthat a large number of homeless individuals rely on hospitals for their health care needssometimes on multiple occasions throughout any given year (Kushel et al 2002)

In Canada homelessness costs the Canadian economy $705bn annually and institutional caresuch as hospitalization contributes significantly to this amount (Gaetz et al 2013) Recentindicators suggest that the annual cost of hospitalization of homeless persons is $2495compared to $524 for housed persons (Gaetz 2012 Hwang and Henderson 2010) Examiningexpenditures in four Canadian cities Pomeroy (2005) calculates the cost of institutionalresponses to homelessness such as hospitalization as adding up to $120000 per personannually Clearly there are social and economic costs associated with inadequate levels of carefor persons experiencing homelessness

Kristy Buccieri is based atTrent UniversityPeterborough CanadaAbram Oudshoorn is AssistantProfessor atWestern UniversityLondon CanadaTyler Frederick is based atthe Institute of TechnologyUniversity of OntarioOshawa CanadaRebecca Schiff is AssociateProfessor atLakehead UniversityThunder Bay CanadaAlex Abramovich isIndependent Scientist atthe Centre for Addiction andMental HealthToronto CanadaStephen Gaetz is based atYork UniversityToronto CanadaCheryl Forchuk is based atWestern UniversityLondon Canada

PAGE 4 j HOUSING CARE AND SUPPORT j VOL 22 NO 1 2019 pp 4-14 copy Emerald Publishing Limited ISSN 1460-8790 DOI 101108HCS-07-2018-0015

Although individuals experiencing homelessness may have a higher acuity or co-morbidconditions that partially explain their more frequent use of hospitals a notable concern is whetherthey are receiving timely and appropriate discharge (Cornes et al 2017) The purpose ofconducting this national survey was to understand how Canadian hospital and homeless-servingstakeholders perceive hospital discharge processes and outcomes for these patients

Canadian context

Canada is a wealthy nation with a population of over 36m The most recent national data indicatethat at least 235000 Canadians experience homelessness every year and that of theseindividuals 273 percent are women 187 percent are youth and within shelter populations244 percent are older than 50 and 28ndash34 percent are identified as indigenous (Gaetz et al2016) Individuals identified as lesbian gay bisexual transgender queer or 2-spirit aredisproportionately represented among the homeless population in Canada (Abramovich 2016Gaetz et al 2016)The homeless population has changed over time in Canada from a smallnumber of single adult males in the 1980s to a mass problem in the mid-2000s (Gaetz et al2016) The increase in homelessness and the demographic changes can be traced to federaldivestment in affordable housing through policy changes made in the 1980s and 1990s thedismantling of Canadarsquos national housing strategy at that time had arguably the most profoundimpact on the rise of homelessness (Gaetz 2010) At present Canada is undergoing a renewedinvestment in affordable housing through new initiatives such as the National Housing Strategy(Government of Canada 2017) and Homelessness Strategy (Government of Canada 2018) Thisshift away from an emergency response toward prevention and transition is in part due to thewidespread adoption of Housing First a recovery-oriented model that aims to rapidly andsecurely house individuals and then provide the wrap-around supports they need Housing Firstwas developed at Pathways to Housing in New York (Padgett et al 2016) and was proveneffective in the landmark multi-site Canadian evaluation of over 2000 participants known as theAt-HomeChez Soi study (Goering et al 2014)

The Housing First approach increasingly being adopted in Canada represents a shift towardintegrated systems approaches (Nichols and Doberstein 2016) This work is informed by the CalgaryHomeless Foundationrsquos (2014) ldquosystems of carerdquo planning which is comparable to the LondonPathway approach (Hewett 2013 Powell and Hewett 2011) There are several national bodies thatinform and advocate for coordinated systems approaches such as the Canadian Observatory onHomelessness and the Canadian Alliance to End Homelessness However the organization ofCanadarsquos political system into federal provincialterritorial and municipal governments makes itchallenging to align factors such as mandates budgets and information sharing (Buccieri 2016)For instance since health care is managed at the provincial and territorial level in Canada there are13 independent ministries that oversee service planning and provision based on geographic locationFurthermore housing is also a provincial-level issue but is overseen by different ministries than healthand many provinces further download housing and homelessness planning to municipalgovernments many of whom operate alongside non-for-profit organizations Thus each level ofgovernment has its responsibilities and oversight but they are not always well integrated

The unintended outcome of this political approach is disjointed health and social care particularlyfor vulnerable populations Canada operates under universal health care but researchers havefound that hospitals have limited resources to meet increasing needs and are frequentlyovercrowded (Zhao et al 2015) While the international standard for safe occupancy is85 percent in the summer of 2017 half of the hospitals in Ontario Canadarsquos most populatedprovince were at or above 100 percent occupancy sometimes reaching as high as 140 percent(Ontario Hospital Association 2018) Delayed discharge can increase occupancy and lead tocapacity strain in emergency departments and increased wait times across the system (Forsteret al 2003) Therefore the fact that 13 percent of hospital beds in Canada are occupied by thoseno longer requiring hospital care but awaiting discharge to an appropriate service (CIHI 2010) isof vital concern The literature review that follows details what is known about hospital usage anddischarge planning for persons experiencing homelessness in Canada and establishes thefoundation for the study


Literature review

Discharging individuals from hospital directly to shelters or the street is common butunder-explored in the Canadian literature (Forchuk et al 2006) Pauly (2014) notes that inCanada clients get ldquodumped into the communityrdquo through discharge to shelters or the streetwithout any discharge planning around housing and community supports However some NorthAmerican research clearly shows that when coordinated discharge planning for homelessindividuals occurs it leads to decreases in hospital visits (Raven et al 2011 Sadowski et al 2009)supports housing stability (Forchuk et al 2008) is cost-effective (Forchuk et al 2013) and ispossible using a systems-approach that integrates sectors (Stergiopoulos et al 2016) throughthe implementation of evidence-based practices (Best and Young 2009) Yet despite this literatureshowing the positive outcomes of coordinated discharge inappropriate or incomplete dischargepractice is a common occurrence for individuals experiencing homelessness

Patients with complex social needs may require a dedicated discharge planner in order for dischargeto occur in a timely manner For people experiencing homelessness increased length of stay is seenboth in acute beds and in Alternate Level of Care beds meaning patients who do not require acutecare resources but remain hospitalized (Hwang et al 2011) While much of the literature on healthcare utilization among those experiencing homelessness focuses on high emergency departmentuse these high rates carry into admitted acute care as well (Fazel et al 2014) For example Hwanget al (2013) analyzed health service utilization among 1165 people experiencing homelessness andfound a 422 rate ratio for medical-surgical hospitalization compared to the general populationSimilarly Russolillo et al (2016) studied admissions and length of stay for 433 individuals in the10 years prior to their intake into a Housing First program they found an average of 6 admissionsover 10 years increasing from 03 to 12 over the 10-year period Likewise mean days in hospitalincreased from 24 to 169 These admissions are in part due to compounding factors of higher ratesof morbidity with lower rates of access to health services in the community such as primary care

Within hospitals patient discharge may be the responsibility of nurses but often they have notreceived training about how to address the non-medical needs of homeless individuals (Doranet al 2014) Without formal instruction health care providers may not know what issues toconsider andor how to address them For instance one American study of discharge practicesfound that over half of the homeless participants were not asked about their housing status(Greysen et al 2013) There are several complicating factors common at discharge for any hospitalpatient including discontinuity between health care providers changes tomedication regimes newself-care responsibilities stressors to available resources and complex discharge instructions(Kripalani et al 2007) In addition to managing these potential difficulties patients experiencinghomelessness live with unstable social situations that may challenge standard discharge care (Bestand Young 2009) This is evidenced in one study of recurrent hospitalization that found thatovercoming difficult life circumstances posed a greater barrier to recuperation than did a lack ofmedical knowledge strongly indicating a need to address underlying issues (Strunin et al 2007)

Following discharge re-presentation to hospital is common for patients experiencinghomelessness (Moore et al 2010) Fader and Phillips (2012) note that patients experiencinghomelessness often lack access to the resources needed to maintain their health independentlySometimes referred to as a ldquotransition of carerdquo (Kripalani et al 2007) properly executeddischarge planning should identify and organize the services that a person with mental illnesssubstance abuse andor other vulnerabilities needs when leaving an institutional or custodialsetting and returning to the community (Backer et al 2007)

Recently some discharge models have begun to identify problem areas and show promisinginterventions for vulnerable patients Medical respite programs for instance have been shown toassist people in their transitions of care from hospital and to provide ongoing support in thecommunity (Fader and Phillips 2012) and coordinated discharge checklists have been shown tobe effective for discharge of patients experiencing homelessness (Best and Young 2009) Amongthe few reported studies on discharge of patients experiencing homelessness from acute mentalhealth services the findings indicate that discharge directly to transitional andor supportive housingdrastically improves housing stability (Forchuk et al 2006 2008 2013) reduces readmission rates(Stergiopoulos et al 2016) and lowers health care expenditures (Forchuk et al 2013)


Research question

Given the high system impact of service utilization by people experiencing homelessness and thelikelihood of delayed discharge more information is needed to understand barriers and gapsregarding timely discharge Therefore this paper addresses the question

RQ1 What are the barriers and system gaps to timely discharge for people experiencinghomelessness from hospital to community in Canada

Methodology

The data presented in this paper were collected through an online survey conducted in July 2017The Canadian Observatory on Homelessness distributed a brief description of the survey and thelink to its members through e-mail and social media accounts The purpose of the survey was tocollect national data on the issues impacting discharge planning for patients experiencinghomelessness To capture a broad range of stakeholders individuals working within health carenon-profit sectors government research or other related fields within Canada were eligible toparticipate A total convenience sample of 660 participants completed the survey All participantsprovided informed consent participation was voluntary and no remuneration was provided torespondents The study was reviewed and approved by the Research Ethics Board for researchinvolving human participants at Trent University

To collect broad data from a large range of stakeholders the survey was intentionally designed totake no more than five minutes to complete and consisted of only eight questions The first sixquestions were basic demographics to situate participants geographically and in specificsectors or roles For the seventh question participants were given a series of eight statements(see Table II) and asked to rate their level of agreement on a scale of 0ndash100 with 100 indicatingthe highest level of agreement For the last question participants were provided with an open boxand asked ldquoIs there anything you would like to say about hospital discharge planning andorcoordinated health care efforts for persons experiencing homelessness in your communityrdquoSlightly more than half (515 percent) of the participants responded to this final question resultingin 340 comments for analysis

Data from each of the eight questions are reported in this paper The geographic employment andstatement data from questions 1 to 7 are presented in chart form The qualitative data fromquestion 8 were analyzed using a method of deductive coding (Guba and Lincoln 1989) movingfrom general to particular themes The quotes were read several times sorted into broad categoriesand divided into sub-themes identifying new ones as they emerged until saturation was achieved

Findings

Demographics

The demographic data indicated that more than half of the participants were located in theprovince of Ontario which is in Central-east Canada Despite being clustered heavily in oneprovince the geographic size was evenly distributed between small mid-size and majormetropolitan areas The majority of participants were employed in the social service or non-profitsector and worked predominantly in non-managerial positions that involved direct contact withpersons experiencing homelessness (Table I)

Scope of the issue

Following from the literature on high rates of hospital usage by persons experiencinghomelessness (Hwang and Henderson 2010 Kushel et al 2002 Mackelprang et al 2014Tadros et al 2016) and discharge planning (Stergiopoulos et al 2016) a series of statementswere constructed for the survey For instance based on Wen et al (2007) finding that individualsexperiencing homelessness often feel unwelcome in health care settings we posed a statementabout how well-supported stakeholders believe these patients are in hospitals Questions about


integration between health care and social care emerged from the work of Nichols andDoberstein (2016) and questions about the discharge process were primarily informed by thepsychiatric discharge studies conducted by Forchuk et al (2006 2008 2013)

Participants were asked to rate their agreement with each statement using a scale of 0ndash100 withhigher numbers indicating stronger agreement Across all statements the data indicated strongconsensus that the need for improved discharge planning for this population is extremely highThe data presented in Table II particularly the median and mode for each statementdemonstrate that stakeholders across Canada are struggling with the negative effects ofuncoordinated discharge planning for persons experiencing homelessness

Barriers and gaps

Participants were given an opportunity to share any information they wished about discharge planningandor coordinated care for persons experiencing homelessness in their community Analysis of the340 submitted responses identified three contributing factors that serve as barriers or gaps to thecoordinated discharge of patients experiencing homelessness from hospital into supportive housing

Communication

Participants particularly those working in shelters expressed frustration over the lack ofcommunication between sectors A characteristic statement was ldquoIn 5 years of working at ashelter for those experiencing homelessness I have never had or witnessed hospital staff(physical or mental health facility) include us in a hospital discharge planrdquo While there wasrecognition that some hospital staff were familiar with the local agencies this was viewed as afunction of the individual and not a systems-level practice Participants expressed that ldquoHospitaldischarge planners are often not aware of the resources in the communityrdquo ldquoHospital socialworkers need to continue to network with the community servicesrdquo and that communication fromhospitals is ldquotoo haphazard and frustratingrdquo Support workers shared the concern that withouttheir involvement discharge plans for their clients were not practical One participant statedldquoWe have occasions when people are discharged without appropriate clothingshoes

Table I Participant demographics

nfrac14660 n n

Geographic location SectorOntario 383 580 Social servicenon-profit 428 608British Columbia 100 152 Hospitalhealth care 125 178Alberta 68 103 Government 56 80Manitoba 22 33 Other (legal emergency) 43 61Nova Scotia 12 18 Research 20 28Quebec 8 12 Education 15 21Newfoundland and Labrador 7 11 Policy 14 20New Brunswick 6 09 Length in position (years)Saskatchewan 6 09 0ndash5 214 349Yukon 2 03 6ndash10 175 286Northwest Territories 1 02 11ndash20 127 201Prince Edward Island 1 02 W21 94 153Geographic size Work involves homelessnessSmaller metropolitan 183 297 Yes directly 529 806Mid-sized metropolitan 178 289 Yes indirectly 120 183Major metropolitan 174 283 No 3 05Non-metro small city 36 58Small town 35 57Decision-maker in organizationNo 405 689Yes 171 291


We have tried to communicate with our hospital to participate in discharge planning but have notbeen successfulrdquo Another wrote ldquoWe have identified a trend in our community whereby thehospital will discharge homeless or mentally ill patients late at night and typically on the weekendin order to place inappropriate clients in our shelterrdquo

Siloing between sectors was identified as a primary reason for the lack of mutual communicationOne participant noted that although their local hospital is trying to improve their dischargeplanning they are ldquodoing so using the typical silo methods that mean they will announce theirprocess changes to community service agencies and then be surprised when those sameagencies donrsquot agree with the changes and wonrsquot complyrdquo Poor communication betweenhospitals and shelters was perceived to be contributing to the ongoing lack of coordinateddischarge for persons experiencing homelessness in Canada

Privacy

The lack of communication was attributable at least in part to privacy concerns around thesharing of confidential information Participants working in social service sectors felt that medicalprofessionals would benefit from their knowledge about the client but that they were not receptiveto non-family members citing health professionals as being ldquooften dismissive of factual evidencewitnessed and provided by shelter staff supporting the individualrdquo One participant wrote

Many times I have tried to share information with a hospital only to be told that this information is not asaccurate as the client Example a client stated that with the minor surgery they were having and the2 days of rest they needed afterwards that they could stay with a family member When I explainedthat would not be the case as the family member lived in another city and that there was no contactwith them due to the addictions of the client I was informed that the hospital will allow him to bedischarged to the family home

For confidentiality reasons hospital staff may be reluctant to accept information from shelterworkers and are even less inclined to provide information One participant stated ldquoEven wherethere is a care plan in place the medical profession and particularly the hospitals are not preparedto share critical information with housing and support provider(s)rdquo

Privacy policies were a source of frustration for many participants working in shelters and non-profitagencies According to one ldquoPrivacy is the main reason given for lack of collaboration withnot-for-profits in the homeless serving sector Itrsquos a cop out I think Models exist that show publichealthnot-for-profit collaboration can have positive impact on the homeless populationrdquo However

It should also be acknowledged that at times communication from hospital to communityorganizations does not occur due to lack of consent from the client At times the client does not wish toengage in discharge planning for a number of reasons and that also needs to be respected

Privacy was identified as a barrier to communication between hospitals and shelters many feltthat while it has to be respected when requested by the client the goal should always be to haveconsent in place so that information can be freely shared

Table II Participant agreement

x Median Mode

Hospital discharge planning for patients experiencing homelessness is an issue that needs to be better addressedin my community 9288 100 100Persons experiencing homelessness have unique health care needs 8914 98 100Improving hospital discharge planning could help reduce chronic homelessness 8298 100 100Persons experiencing homelessness are usually discharged from hospitals to the streets or a shelter 8267 91 100Hospitals and homelessness sector agencies work well together to coordinate care 2433 20 0Persons experiencing homelessness are well supported in health care settings 2207 20 0Persons experiencing homelessness are usually discharged from hospitals with treatment plans that are clear andeasy to follow 1756 10 0Persons experiencing homelessness are usually discharged from hospitals into supportive housing 1109 4 0


Systems pressures

Each sector has its own pressures that negatively impact their ability to engage in coordinateddischarge planning for persons experiencing homelessness Hospitals experience the burdens ofbeing ldquounder so much utilization wait times and flow pressures their focus is narrow and thegoal is time and resource efficiencyrdquo While some participants noted that ldquoHolding onto patientsfor an extra day or two is very helpfulrdquo the general consensus from hospital staff was that ldquowe arenot able to keep patients in the hospital just because of housingrdquo and that ldquothere are literally nofree beds in hospitalsrdquo As one participant wrote ldquoOften the pressure of lsquomaking beds freersquo putspeople in vulnerable situations when they are discharged Itrsquos a broken system and the mostvulnerable people are falling through the cracksrdquo Individuals working within hospitals were equallyfrustrated with the lack of beds and pressure to discharge but felt confined by the policies of theirinstitutions ldquoIndividual hospital staff are flexible and patient-centred It is systemic policies suchas hospital performance measures regarding length of stay that are the barriersrdquoOvercoming thebarriers can require extreme measures such as one community outreaches nurse who recalledblocking an unsafe discharge from the ICU ldquoby withholding an electric wheelchair so the personhad no means of leaving the hospitalrdquo Participants stated that ldquoNobody wants to discharge apatient back to the shelter it is a terrible situation for everyone involved especially the patientrdquo butthat ldquoIt is not about improving the discharge plan itrsquos (about) changing the policiesrdquo

Discharge to shelter was not considered to be a viable option by many participants For instancethey stated that ldquoShelter services are not equipped to provide the level of care or support for theseindividualsrdquo ldquoshelter staff are not typically trained in proper after-care or one-to-one care thatmany patients needrdquo and that to protect their wellness sometimes the only option is ldquoadvocatingthat the client cannot return to the shelterrdquo Without on-site health care shelters are rarely asuitable option for patients with medical needs What these patients often require is home carebut ldquowith no known address it is virtually impossible to providerdquo However just as there arelimited beds in hospitals ldquoThere is no housing You can discharge plan all you want but waitingfor housing would mean inpatient stays for years and yearsrdquo The lack of affordable housing wasbelieved to undermine any efforts at discharge planning Several participants wrote about the lackof affordable housing options in Canada as being a crisis Participants wrote that ldquoPeople need toactually transition out of transitional housing there is no movement in the housing crisisrdquoldquoHospital discharge planning is only a small piece of a much larger crisis There is little in the wayof affordable housing in this cityrdquo ldquoHospitals can do better to coordinate discharge planning withshelters but they cannot fix the crisis We need access to affordable housingrdquo Pressure is put onhospital staff to free up beds but the lack of affordable housing stock means that personsexperiencing homelessness have nowhere to go Accordingly ldquoOne can have all the coordinatedefforts they can muster but if there is no place for people to go it is a bit like shoutinginto the abyssrdquo

Discussion

The federal decision to withdraw from affordable housing in the 1980s and 1990s has led to anincrease of homelessness in Canada with current annual figures reaching 235000 individuals and acost of $705bn (Gaetz et al 2013 2016) At the same time Canadian hospitals are facing chronicovercrowding (Ontario Hospital Association 2018 Zhao et al 2015) and a 13 percent bedoccupancy rate for patients who are not in need of medical care but lack appropriate referral services(CIHI 2010) Furthermore Canadian research indicates that persons experiencing homelessnessare frequent hospital users (Hwang and Henderson 2010) contribute to the high cost of healthcare provision (Gaetz 2012 Pomeroy 2005) and are commonly discharged to shelters orthe street (Pauly 2014) Given these combinations of factors the current study soughtto obtain stakeholder opinions on the state of hospital discharge planning for patientsexperiencing homelessness

This paper reported findings from a survey of 660 national stakeholders in Canada Theresearch question guiding this investigation was ldquoWhat are the barriers and system gaps totimely discharge for people experiencing homelessness from hospital to community inCanadardquo Consideration of the scope of the issue was based on knowledge from the


literature and revealed strong consensus that persons experiencing homelessness have uniquehealth care needs improving discharge planning for this population could help reduce chronichomelessness and persons experiencing homelessness are usually discharged to thestreet or a shelter Results also indicated a strong general consensus that hospitals andhomelessness sector agencies do not work well together to coordinate care personsexperiencing homelessness are not well supported in health care settings patientsexperiencing homelessness are not usually discharged with plans that are clear and easy tofollow and these individuals are rarely discharged into supportive housing These findingssupport the literature from Canada and the USA that shows individuals experiencinghomelessness often have complex health needs that lead them to seek hospital care (Kushelet al 2002 Mackelprang et al 2014 Tadros et al 2016) discharge is currently not wellcoordinated between hospitals and community supports (Pauly 2014) and that coordinateddischarge into supportive housing could reduce hospital visits (Raven et al 2011 Sadowskiet al 2009) and increase housing security (Forchuk et al 2006 2008 2013)

Analysis of the qualitative data was conducted to identify the current barriers and gaps thatprevent coordinated discharge of patients experiencing homelessness A general lack ofcommunication was an issue particularly with hospital staff not reaching out to agencies whencommunication did occur it was usually because of the individual staff member being aware ofservices and not because of institutional practices As previously noted within Canada healthcare is a provincial matter but many service providers are municipally funded or not-for-profitWorking across governments and sectors reduces communication and leads to a lack oftransparency When communication lacked the non-profit workers generally felt that claims toprivacy were made While they supported client-requested privacy many felt that hospitals usedprivacy as a shield for not providing or accepting information about shared clients Shareddatabases in community services have shown that multi-agency information sharing is possiblewith proactive consent Systems integration is increasingly becoming recognized in Canada(Nichols and Doberstein 2016) but has been slow to move from theory to practice

The third barrier identified was the existing system pressure on hospitals shelters and affordablehousing stock It is well documented that hospitals in Canada are at- or over- capacity (Zhaoet al 2015) and that despite the adoption of Housing First (Goering et al 2014) there are highrates of homelessness and limited affordable housing (Gaetz et al 2016) Survey participantswere particularly frustrated with what they described as crisis-level situations whereby there wereno free beds to keep patients in hospital limited medically equipped shelters and no housingoptions available These systems pressures meant that individuals had to sometimes undertakeextreme measures such as withholding a wheelchair at hospital or refusing admission at ashelter to prevent early or inappropriate discharge While participants perceived individuals withinthese systems to be client-centered there was a consensus that the pressures of high demandand low capacity pervaded hospitals and housing sectors

Some models of discharge planning such as direct entry into supportive housing uponpsychiatric discharge have been effective in Canada (Forchuk et al 2006 2008 2013) butwithout more affordable housing stock across the country the implementation of this method willbe restricted In the shortage of affordable housing options medical respite programs (Fader andPhillips 2012) may be an alternate option that serve as an intermediary between hospitals andhousing relieving some of the identified systems pressures Coordinated discharge checklistsshown to be effective (Best and Young 2009) may also improve communication if they areadapted to be jointly shared across sectors Effective and sustainable approaches to dischargefor patients experiencing homelessness are possible but will require consideration ofcommunication privacy and constraints within the existing systems

Limitations

The data were collected through an online survey of national stakeholders Given its distributionthrough the Canadian Observatory on Homelessness there was likely a self-selection bias inwhich participants who were actively working in homelessness agencies or with personsexperiencing homelessness were more likely to respond This is supported by the


high percentage of non-profit workers Additionally the survey was predominantly completed inthe province of Ontario and may have had different results if more geographically dispersedNo patient views were collected in this study

Conclusion

Within Canada hospitals and affordable housing are both at full-capacity and working at oddswith one another The national adoption of Housing First while having the potential to rapidlyhouse individuals in need such as those leaving hospitals is only possible if a sustainable sourceof affordable housing exists Canada is on the verge of another major shift in its approach tohomelessness reversing the federal devolution of affordable housing with the 2018 NationalHousing Strategy (Government of Canada 2017) and Homelessness Strategy (Government ofCanada 2018) Reducing the burdens on health care and housing sectors requires that they beviewed and funded as two interconnected issues and not as parallel systems As these newinitiatives unfold Canadian leaders are called upon to invest in affordable housing as a means ofsupporting Housing First and offering a resource for hospital discharge planners Coordinateddischarge for persons experiencing homelessness would help improve the capacity ofboth sectors but it depends on overcoming the barriers of communication privacy andsystems pressures

References

Abramovich A (2016) ldquoPreventing reducing and ending LGBTQ2S youth homelessness the need fortargeted strategiesrdquo Social Inclusion Vol 4 No 4 pp 86-96

Backer TE Howard EA and Moran GE (2007) ldquoThe role of effective discharge planning in preventinghomelessnessrdquo Journal of Primary Prevention Vol 28 Nos 3-4 pp 229-43

Best JA and Young A (2009) ldquoA SAFE DC a conceptual framework for care of the homeless inpatientrdquoJournal of Hospital Medicine Vol 4 No 6 pp 375-81

Buccieri K (2016) ldquoIntegrated health and housing care for homeless and marginally housed individuals astudy of the housing and homelessness steering committee in Ontario Canadardquo Social Sciences Vol 5No 2 p 15

Calgary Homeless Foundation (2014) System Planning Framework Calgary Homeless Foundation Calgary

CIHI (2010) Health Care in Canada 2010 Evidence of Progress But Care Not Always Appropriate CanadianInstitute for Health Information Ottawa

Cornes M Whiteford M Manthorpe J Neale J Byng R Hewett N Clark M Kilmister A Fuller JAldridge R and Tinelli M (2017) ldquoImproving hospital discharge arrangements for people who are homelessa realist synthesis of the intermediate care literaturerdquo Health and Social Care in the Community Vol 26 No 3pp 345-59

Doran KM Curry LA Vashi AA Platis S Rowe M Gang M and Vaca FE (2014) ldquolsquoRewarding andchallenging at the same timersquo emergency medicine residentsrsquo experiences caring for patients who arehomelessrdquo Academic Emergency Medicine Vol 21 No 6 pp 673-9

Fader H and Phillips C (2012) ldquoFrequent-user patients reducing costs while making appropriatedischargesrdquo Healthcare Financial Management Vol 66 No 3 pp 98-100

Fazel S Geddes JR and Kushel M (2014) ldquoThe health of homeless people in high-income countriesdescriptive epidemiology health consequences and clinical and policy recommendationsrdquo The LancetVol 384 No 9953 pp 1529-40

Forchuk C Russell G Kingston-MacClure S Turner K and Dill S (2006) ldquoFrom psychiatric ward to thestreets and sheltersrdquo Journal of Psychiatric and Mental Health Nursing Vol 13 No 3 pp 301-8

Forchuk C MacClure SK Van Beers M Smith C Csiernik R Hoch J and Jensen E (2008)ldquoDeveloping and testing an intervention to prevent homelessness among individuals discharged frompsychiatric wards to shelters and lsquono fixed addressrsquordquo Journal of Psychiatric and Mental Health NursingVol 15 No 7 pp 569-75


Forchuk C Godin M Hoch JS Kingston-MacClure S Jeng MS Puddy L Vann R and Jensen E(2013) ldquoPreventing psychiatric discharge to homelessnessrdquo Canadian Journal of Community Mental HealthVol 32 No 3 pp 17-28

Forster AJ Stiell I Wells G Lee AJ and Van Walraven C (2003) ldquoThe effect of hospital occupancy onemergency department length of stay and patient dispositionrdquo Academic Emergency Medicine Vol 10 No 2pp 127-33

Gaetz S (2010) ldquoThe struggle to end homelessness in Canada how we created the crisis and how we canend itrdquo The Open Health Services and Policy Journal Vol 3 No 2 pp 21-6

Gaetz S (2012) The Real Cost of Homelessness Can we Save Money by Doing the Right Thing CanadianHomelessness Research Network Press Toronto

Gaetz S Dej E Richter T and Redman M (2016) The State of Homelessness in Canada 2016 CanadianObservatory on Homelessness Press Toronto

Gaetz S Donaldson J Richter T and Gulliver T (2013) The State of Homelessness in Canada 2013Canadian Homelessness Research Network Press Toronto

Goering P Veldhuizen S Watson A Adair C Kopp B Latimer E and Aubry T (2014) National FinalReport Cross-Site at HomeChez Soi Project Mental Health Commission of Canada Calgary

Government of Canada (2017) A Place to Call Home Canadarsquos National Housing Strategy Government ofCanada Ottawa

Government of Canada (2018) Reaching Home Canadarsquos Homelessness Strategy Government ofCanada Ottawa

Greysen SR Allen R Rosenthal MS Lucas GI and Wang EA (2013) ldquoImproving the quality ofdischarge care for the homeless a patient-centered approachrdquo Journal of Health Care for the Poor andUnderserved Vol 24 No 2 pp 444-55

Guba EG and Lincoln Y (1989) Fourth Generation Evaluation Sage Newbury Park CA

Hewett N (2013)Closing the Gap through Changing Relationships Final Report for Closing the Gap throughChanging Relationships The London Pathway London

Hwang SW and Henderson M (2010) Health Care Utilization in Homeless People Translating Researchinto Policy and Practice Agency for Healthcare Research amp Quality Rockville MD

Hwang SW Weaver J Aubry T and Hoch JS (2011) ldquoHospital costs and length of stay among homelesspatients admitted to medical surgical and psychiatric servicesrdquo Medical Care Vol 49 No 4 pp 350-4

Hwang SW Chambers C Chiu S Katic M Kiss A Redelmeier DA and Levinson W (2013)ldquoA comprehensive assessment of health care utilization among homeless adults under a system of universalhealth insurancerdquo American Journal of Public Health Vol 103 No S2 pp S294-301

Kripalani S Jackson AT Schnipper JL and Coleman EA (2007) ldquoPromoting effective transitions of care athospital discharge a review of key issues for hospitalsrdquo Journal of Hospital Medicine Vol 2 No 5 pp 314-23

Kushel MB Perry S Bangsberg D Clark R and Moss A (2002) ldquoEmergency department use amongthe homeless and marginally housed results from a community-based studyrdquo American Journal of PublicHealth Vol 92 No 5 pp 778-84

Mackelprang JL Graves JM and Rivara FP (2014) ldquoHomeless in America injuries treated in US emergencydepartments 2007ndash2011rdquo International Journal of Injury Control and Safety Promotion Vol 21 No 3 pp 289-97

Mikkonen J and Raphael D (2010) Social Determinants of Health The Canadian Facts York UniversitySchool of Health Policy and Management Toronto

Moore G Gerdtz M Hepworth G and Manias E (2010) ldquoHomelessness patterns of emergencydepartment use and risk factors for re-presentationrdquo Emergency Medicine Journal Vol 28 No 5 pp 422-7

Nichols N and Doberstein C (Eds) (2016) Exploring Effective Systems Responses to HomelessnessCanadian Observatory on Homelessness Press Toronto

Ontario Hospital Association (2018) ldquoA sector on the brink the case for a significant investment in Ontariorsquoshospitalsrdquo available at wwwohacomBulletins2558_OHA_A20Sector20on20the20Brink_revpdf(accessed July 18 2018)


Padgett D Henwood BF and Tsemberis SJ (2016) Housing First Ending Homelessness TransformingSystems and Changing Lives Oxford University Press New York NY

Pauly B (2014) ldquoClose to the street nursing practice with people marginalized by homelessness andsubstance userdquo in Guirguis-Younger M McNeil R and Hwang SW (Eds) Homelessness and Health inCanada University of Ottawa Press Ottawa pp 211-32

Pomeroy S (2005) The Cost of Homelessness Analysis of Alternate Responses in Four Canadian CitiesNational Secretariat on Homelessness Ottawa

Powell L and Hewett N (2011) Pathway Needs Assessment at Brighton and Sussex University HospitalThe London Pathway London

Raven MC Doran KM Kostrowski S Gillespie CC and Elbel BD (2011) ldquoAn intervention to improvecare and reduce costs for high-risk patients with frequent hospital admissions a pilot studyrdquo BMC HealthServices Research Vol 11 p 270

Russolillo A Moniruzzaman A Parpouchi M Currie LB and Somers JM (2016) ldquoA 10-yearretrospective analysis of hospital admissions and length of stay among a cohort of homeless adults inVancouver Canadardquo BMC Health Services Research Vol 16 No 1 p 60

Sadowski L Romina K VanderWeele T and Buchanan D (2009) ldquoEffect of a housing and casemanagement program on emergency department visits and hospitalizations among chronically ill homelessadultsrdquo JAMA Vol 301 No 17 pp 1771-8

Stergiopoulos V Gozdzik A Tan de Bibiana J Guimond T Hwang SW Wasylenki DA and LeszczM (2016) ldquoBrief case management versus usual care for frequent users of emergency departments thecoordinated access to care from hospital emergency departments (CATCH-ED) randomized control trialrdquoBMC Health Services Research Vol 16 No 1 p 432

Strunin L Stone M and Jack B (2007) ldquoUnderstanding rehospitalization risk can hospital discharge bemodified to reduce recurrent hospitalizationrdquo Journal of Hospital Medicine Vol 2 No 5 pp 297-304

Tadros A Layman SM Pantaleone Brewer M and Davis SM (2016) ldquoA 5-year comparison of ED visitsby homeless and nonhomeless patientsrdquo American Journal of EmergencyMedicine Vol 34 No 5 pp 805-8

Wen CK Hudak PL and Hwang SW (2007) ldquoHomeless peoplersquos perceptions of welcomeness andunwelcomeness in healthcare encountersrdquo Journal of the Society of General Internal Medicine Vol 22 No 7pp 1011-7

Zhao Y Peng Q Strome T Weldon E Zhang M and Chochinov A (2015) ldquoBottleneck detection forimprovement of emergency department efficiencyrdquo Business Process Management Journal Vol 21 No 3pp 564-85

Corresponding author

Kristy Buccieri can be contacted at kristybuccieritrentuca

For instructions on how to order reprints of this article please visit our websitewwwemeraldgrouppublishingcomlicensingreprintshtmOr contact us for further details permissionsemeraldinsightcom


The GP role in improving outcomesfor homeless inpatients

Zana Khan Philip Haine and Samantha Dorney-Smith

Abstract

Purpose ndash Homeless people experience extreme health inequalities and high rates of morbidity and mortality(Aldridge et al 2017) Use of primary care services are low while emergency healthcare use is high (Mathie2012 Homeless Link 2014) Duration of admission has been estimated to be three times longer for homelesspatients who often experience poor hospital discharge arrangements (Mathie 2012 Homeless Link 2014)This reflects ongoing and unaddressed care and housing needs (Blackburn et al 2017) The paper aims todiscuss these issuesDesignmethodologyapproach ndash This paper reveals how GPs employed in secondary care as part ofPathway teams support improved health and housing outcomes and safe transfer of care into communityservices It draws on published literature on role of GPs in working with excluded groups personal experienceof working as a GP in secondary care structured interviews with Pathway GPs and routine data collected bythe team to highlight key outcomesFindings ndash The expertise of GPs is highlighted and includes holistic assessment management ofmultimorbidity or ldquotri-morbidityrdquo ndash the combination of addictions problems mental illness and physical health(Homeless Link 2014 Stringfellow et al 2015) and research and teachingOriginalityvalue ndash The role of the GP in the care of patients with complex needs is more visible in primarycare This paper demonstrates some of the ways in which in-reach GPs play an important role in the care ofmultiply excluded groups attending and admitted to secondary care settings

Keywords Homeless Inpatients Excluded groups GP Inclusion health Pathway


Introduction

It is recognised that homelessness and social exclusion are not simply housing or social issues buthave profound health consequences (Homeless Link 2014 2017 Aldridge et al 2017) Peoplewho are homeless or from excluded groups experience two to five times higher mortality andmorbidity rates across all ICD-10 categories compared to the general population (Aldridge et al2017) The reported mean age of death for people who are homeless is 43ndash47 (Thomas 2012)compared to 74ndash80 in the general population is (Crisis 2011) Homelessness is characterisedby complex health needs (Fazel et al 2014) often described as ldquotri-morbidityrdquo ndash the combinationof physical illness mental illness and substance misuse (Stringfellow et al 2015) It is alsorecognised that people with a combination of multiple overlapping needs have ineffective contactswith services which frequently focus on addressing one problem (Bramley et al 2015 Davies andLovegrove 2016)

Many diseases affecting excluded groups are preventable or treatable with establishedinterventions yet uptake of preventative and scheduled healthcare is low (Luchenski et al2017) because of poorer access to health and care services than the general population(Homeless Link 2014 2017 Story et al 2014 Mann et al 2015 Elwell-Sutton et al 2017)Barriers to accessing services include perceived stigma and discrimination (Rae and Rees2015) making and keeping appointments (Rae and Rees 2015) difficulty registering with a GPdue to lack of ID and address (Homeless Link 2014) competing priorities (Collier 2011) and

Zana Khan is GP Clinical LeadKHP Pathway Homeless Teamat Lambeth HospitalLondon UKPhilip Haine is based at Guyrsquosand St Thomasrsquo NHSFoundation Trust London UKSamantha Dorney-Smith isNursing Fellow at PathwayLondon UK


communication difficulties or challenging behaviour (Bramley et al 2015 Davies andLovegrove 2016 Homeless Link 2017) As a consequence people who are homelessattend AampE five times as often are admitted three times as often and hospital stay is threetimes longer than the housed population (Office of the Chief Analyst 2010) Homelessadmissions are largely unplanned costs are eight times higher than those for the generalpopulation yet hospital discharge arrangements are frequently poor (Office of the Chief Analyst2010 Homeless Link 2015)

Homelessness social exclusion and inclusion health

Rough sleeping is the most visible form of homelessness but many homeless people alsoreside in temporary hostel placements Rough sleeping has increased by 169 per cent since2010 (Ministry of Housing communities and Local Government 2017) However it is thehidden homeless population that are more difficult to measure These include people who areldquosofa surfingrdquo ( living temporarily with others) living in squats or other unsuitableaccommodation and temporary accommodation such as bed and breakfasts (Fitzpatricket al 2018) Other socially excluded groups include sex workers gypsies and travellersprisoners and migrants (Davies and Lovegrove 2016 Aldridge et al 2017 Luchenskiet al 2017) Social exclusion frequently intersects with homelessness (Fitzpatrick et al 2011Manthorpe et al 2015) and both have similar patterns of heath deterioration resulting in someof the poorest health outcomes in society (Aldridge et al 2017)

More recently the term inclusion health has been used to describe the health and careand needs of socially excluded group Inclusion health is an emerging service research policyand practice agenda that aims to prevent and redress health and social inequities amongthe most vulnerable and excluded populations (Luchenski et al 2017) It is founded on thepremise that because of their complex social context and situated experience of multipledisadvantage certain groups in society do not have access to the highest standards ofhealth and care (Levitas et al 2007 Davies and Lovegrove 2016) It is this agenda that isdriving the development of specialist healthcare provision for homeless and other sociallyexcluded groups

Method

This paper reviews existing literature to understand how the role of the specialist GP in homelessand inclusion health has become established in primary and secondary care settings It draws onthe personal experiences and observations of GPs working in a specialist in-reach homelessteam in South London This is supplemented by routine clinical and demographic data (eg eachepisode of care and includes demographics at admission interventions and outcomes atdischarge) collected by the Pathway team Relevant findings from structured interviews(undertaken by the Pathway Nurse Fellow) of ten pathway homeless team staff are also drawnupon The interviews were conducted on a face-to-face basis or over the phone with pointsrecorded and themes drawn and summarised

Primary care homelessness and inclusion health

In the UK and internationally health systems have identified the potential for GPs to providespecialist services to excluded groups such homeless people refugees and asylum seekers aswell as those with substance misuse problems (Ford and Ryrie 2000 Blackburn 2003 Beggand Gill 2005 Johnson et al 2008) In response to the rise in visible and hidden homelessness inthe UK specialist homeless GP practices are offering services that seek to address the complexhealth needs of homeless and excluded patients GPs are able to draw on their specialist trainingand clinical skills to manage multiple and often complex problems in a single consultationThe expert generalist skills of GPs is one reason why primary care has been the focus of suchinnovation (Hewett and Halligan 2010) As such specialist GP in-reach provision is associatedwith care co-ordination person centred and often multidisciplinary specialist or enhanced care(Aspinall 2014 Mehet and Ollason 2015)


GP-led pathway homeless teams in secondary care

Following a needs assessment in 2009 the Pathway Charity implemented a model of GP andnurse-led homeless hospital ward rounds at University College Hospital London The firstpathway homeless team model was based on a similar service run by consultants working withinwith a community-based homeless healthcare team in Boston USA (wwwbhchporg) Giventhe success of GPs in tackling complex health issues in excluded groups in primary care the roleof the GP was identified as an essential part of an inpatient homeless hospital service Key tasksinclude reviewing clinical and discharge goals assisting with care planning explaining medicalfindings communicating with multiple teams and service providers and planning safe discharges(Hewett et al 2012) Pathway homeless teams have since been established in the UK andAustralia including the first team in a Mental Health Trust in South London (wwwpathwayorgukteams) As Pathway teams have evolved over time so has the role of the GP within each teamThe changing role of the GP reflects in part the specific needs and challenges within a localityand the population The type of GP roles within pathway homeless teams include

GPs working as part of pathway homeless team employed by a hospital trust

GPs working within practice in-reaching into a hospital trust and

pathway plus which includes a GP practice in-reaching into secondary care and supported bytransitional services for patients at discharge

Overview of the Kings Health Partners (KHP) pathway homeless teams

Following an urban multicentred needs assessment in south east London (Hewett andDorney-Smith 2013) the KHP pathway homeless team service was initiated at Guyrsquos andSt Thomasrsquo (GStT) and Kings College Hospital (KCH) in January 2014 The service expanded toSouth London and Maudsley (SLaM) in February 2015 The service aims to improve healthand housing outcomes for homeless people admitted to hospital improve quality of care andreduce delayed or premature discharges from hospital (Dorney-Smith et al 2016) There arethree teams based within the three trusts GStT Kingrsquos and SLaM each with a slightly differentstaff configuration Across the three teams staff include two part time GPs a social worker anoccupational therapist (OT) two general nurses two mental health practitioners (who have beenfrom occupational therapy and nursing backgrounds) a business manager 45 housing workers06 peer advocate and a network of volunteers overseen by operational managers at each site

Training and education of the KHP pathway homeless team GPs

In mainstream primary care a lack of training and clinical expertise in managing complex needs hasbeen identified as a barrier to providing care for homeless patients Where this has been providedGPs report feeling more confident to effectively care for homeless patients (Ford and Ryrie 2000)In recognition of this pathway delivered a two-week training course covering substance misusemanaging complexity and statutory homelessness prior to the launch of the KHP pathwayhomeless team The training also included workshops on developing the teamrsquos assessment formand data collection procedures Timewas also spent shadowing existing pathway homeless teams

The role of the GP within the KHP pathway homeless teams personal experience

Organising education and CPD in the field Early in the servicersquos development the need forcontinuing education was identified around welfare benefits particularly in relation to EuropeanEconomic Area (EEA) nationals housing and immigration law and common clinical conditionsaffecting homeless people With previous experience in education the GP organised a rollingprogramme of education (some free and some paid for out of the team training budget) utilisingcolleagues and education providers with expertise in the identified areas including

the No Recourse to Public Funds (NRPF) Network (wwwnrpfnetworkorguk)ndash NRPFand Care act

shelter ndash EEA benefits


Southwark Law Centre ndash legal aspects of homelessness and

consultants and wider colleagues ndash clinical and care topics

There remains a lack of formal accessible and accredited education in the field of Inclusion HealthThis deficit has been acknowledged by Pathway GPs have also sought to bridge this gap byrunning continuous professional development (CPD) days in Brighton and interprofessionaltraining in London One of the GPrsquos who facilitated these sessions is hoping to secure a doctoralgrant to develop educational interventions for healthcare professionals having identified this as akey factor in improving outcomes for homeless inpatients Another GP is also a researcher andleading on research in the field of end-of-life care for homeless people (Table I)

Day-to-day role Given the differences between hospital trusts locally delivered services andregions in the UK it is not possible to directly replicate services and roles between different sitesThe ethos core values and team model remain consistent even when the local context and itschallenges differ (Table II)

Within the KHP pathway homeless teams Band 7 team members oversee the day-to-day runningof the service with the GP providing senior clinical oversight and leadership Band 7srsquo within theteam include nurses social workers and occupational therapists (OTs) The team member withresponsibility for managing a patientrsquos care and discharge needs is determined by presentingneeds and which team member has the most appropriate skill set In addition to the GPrsquos role inoverseeing the teamrsquos caseload the Band 7srsquo support the GP to highlight cases for review andundertake specific actions The GP reviews each patient with the team member leading on thecase or sometimes in collaboration with several teammembers A key feature of the role of in-reachGP is to meet with patients and undertake a detailed clinical review of their current and previousadmissions so as to clinically maximise the benefit of the admission This involves building rapportexploring health issues and barriers to accessing services It also involves understanding eachpatientrsquos expectations of the discharge process and how input from the wider team can facilitate

Table I Basic training and education delivered to the KHP pathway homeless team

Inclusion health generic CPD Inclusion health clinical CPD Mandatoryother training

NRPF BBVs and infectious diseases Basic life supportHousing and immigration Law Alcohol Child and adult safeguardingCare act Substance misuseclub drugs Information governanceBenefits and PIP Sepsis (blood gases) Organisation specific trainingMCA and MHA Pain management (in opiate dependents) Any patient groups that you see regularlyPresenting to panel Mental health (SMI personality disorder dual

diagnosis)Teaching course (offer to teach FY12GPregistrars)

Commissioning of services local serviceprovision

Deep tissue abscess leg ulcers and DVT Homeless health website pathway conference links

Research and evaluation skills writing reportstenders

Palliative and end-of-life care Anything that you need to stay up to date in yourprofession

Table II Experience of the GPs recruited to the KHP pathway homeless teams

Employment Leadership skills Wider experience

Previous experience working in homeless general practice or inner city generalpractice

Clinical leadership in previous roles Teaching and education

Working in acute and unscheduled care settings Service development experience Research andpublications

Working for another pathway homeless team Global health and infectious diseasetraining

Masters or PhD

Prison health experience Appraiser role Linked to a university


positive outcomes The GP must listen to the concerns of team members and may need torespond rapidly if a team member feels a patient needs an urgent clinical review

As with the first pathway homeless team at UCL GPs bring generalist skills (eg biopsychosocialand holistic assessments) and specialist skills into secondary care to support the homelessteam and hospital staff responds to the clinical aspects of a patientrsquos complex situationBuilding relationships with consultants and ward-based medical teams to facilitate effectivecommunication and shared understanding is essential to improve health and housing outcomesfor homeless patients Consultants have a direct influence on ward staff and junior doctorsmaking their engagement with the pathway team pivotal to its success Feedback suggests thatonsultants value the input of a specialist GP and have embraced the role as part of the trustrsquosremit GPs continue to provide support in respect of management substance misuse issues(such as withdrawal from drugs or alcohol) mental illness and complex multimorbidity A furtheraspect of the GPrsquos role is to advocate on behalf of patients with complex and overlapping needsThe GP will regularly write clinical letters for patients in support of a statutory homelessnessapplication or as part of the referral process for supported accommodation These expert lettersinclude key information required by medical assessors within housing departments to make aninformed decision as to whether someone is in ldquopriority needrdquo Clinical letters are used bysupported accommodation pathway managers to make decisions about the most appropriateplacement for a patient upon discharge The letters are written in collaboration with other teammembers to ensure accuracy and relevance

Clinical care and communication The clinical areas most in need of intervention includesubstance misuse management withdrawal assessing cognitive impairment (particularly inyounger patients) harm reduction and safe treatment planning of patients with complicatedinfections or patients who are chaotic At SLaM clinical work includes management ofmultimorbidity and chronic disease Consideration must also be given to the wider care andsupport needs of patients with dual diagnosis (ie the combination of severe mental healthproblems and problematic substance misuse)

The ongoing pressures for beds mean negotiating bed stays for patients who are consideredmedically or psychiatrically fit but who need community follow up and housing continues to bean ongoing challenge Helpful actions to avoid a premature discharge from hospital includecommunicating the risks of readmission and lack of parity of care with housed patients attendingand organising ward-based multidisciplinary team (MDT) meetings and regular contact withsenior clinicians and nurses

The GP at GStT hospital attempted to incorporate preventative healthcare referred to as ldquoprimarycare in-reachrdquo (Dorney-Smith et al 2016) Progress was hampered by a lack of governancearrangements for follow-up of test results dedicated resources to deliver prevention (such asimmunisations) and clear commissioning responsibilities The GP working at GStT was also thelead for the SLaM (Mental Health) trust where routine screening of common health issues (bloodborne viruses cholesterol thyroid function and diabetes) is part of the assessment of newlyadmitted patients thus highlighting that this type of care can be delivered routinely

Complex case management Inpatients with health housing or care needs but who lackentitlements to statutory services or have NRPF remain some of the most challenging tomanage The role of the GP is to ensure that the clinical needs of the patient which are frequentcomplex are understood and prioritised To achieve the best possible outcome the GP and thewider team aim to support care planning by communicating the options available to ward staffand senior clinicians A legal advice service provided in collaboration with Southwark Law Centrehas been a valuable to help the team in advocating for patients with legal and immigration issues

Service development and data collection Due to an increasing number of patients with complexneeds being referred to the pathway homeless team weekly MDTs and twice daily caseloadreviews have become a central feature of the service model Consequently the GP role hasexpanded to develop clinical protocols administrative process and service development acrossthe three hospital Trusts Communicating outputs at local and national levels to support ongoingfunding and sharing experiences and learning is also important (Table III)


From 2015 the KHP pathway homeless teams was asked to deliver a number of key performanceindicators including services activities interventions outputs (eg improved housing status) andoutcomes (eg bed days and readmission rates) The GPs work closely with the business managerand operational leads to ensure that data is collected accurately and with relevant analysisThis proved to be a challenge with the introduction of EMIS Web as a patient record alongside thehospital patient record systems It led to duplication of recording increased administration and lackof EMIS search methodology were challenging to resolve After working closely with the businessmanager an acceptable and accurate mixed methods data collection approach was agreed

Community partnerships Building relationships with community homeless health teams andprimary care is essential for effective transfer of care and the establishment of clear channels ofcommunication The GP and other teammembers maintain regular contact with community-basedhomelessness nursing teams in London (the homeless health team and health inclusion team) aswell as dedicated homeless GP practices and those that offer enhanced services This is furthersupported the use of EMIS Web a primary care record system also used by the Health InclusionTeam and which is now used by other pathway teams and healthcare providers across Londonwith work almost complete to develop data sharing

Hospital cultural change within the KHP pathway homeless teams The presence of a GP andpathway homeless team within the Trust has facilitated cultural change within each participatingorganisation The GP regularly communicates with consultants and senior managementproviding a senior clinical presence for the service and ensuring that challenges anddisagreements are discussed and resolved At SLaM the GP regularly attends psychiatricconsultant meetings at Lambeth and Southwark hospital sites and in the acute trusts is the keycontact for clinical directors and for implementing clinical improvement and patient safetyagendas Examples of this include improving clinical coding of homelessness and related healthissues on Trust databases co-ordinating referrals to the patient safety team of deaths ofhomeless people within the hospital and overseeing the introduction of a clinical reviewspreadsheet and contributing to the steering group for a hepatitis C study

Examples of service development by GPs in the KHP pathway homeless team Servicedevelopment 1 clinical coding

Problem the acute trust was working to improve quality of clinical coding Accurate codingresults in recognition of the complexity of patients attending the trust and confers appropriateremuneration for hospital admissions Key codes include homelessness co-morbidities such asabnormal liver function or renal impairment and lifestyle factors such a smoking or drug use

The clinical lead for coding met the team to discuss how they could help improve clinical codingThe coding lead provided cards summarising the most important codes and showed the teamhow to add clinical codes into the trust database

Table III Activities of the GPs within the KHP pathway homeless team

Core clinical interventions Core leadership skills

Detailed clinical assessment and review Undertake clinical audit and supporting data collectionBuilding rapport with patients and communicating health issues Writing reports and communicating data analysisEncouraging engagement with clinical care Promoting safe care and planning of complex patientsMedication review and treatment advice Challenging stigma and negative opinionsMental capacity and cognitive assessments Teaching and education of staff and studentsAdvocate for preventative healthcare Service evaluation quality and efficiency of the serviceExpert letters of support for accommodation Communicating with senior managementCare planning and alerts Service developmentAssess support needs and address safety issues Presenting work of the team at local and national conferences and eventsNegotiating clinical care and transfer of care Linking with primary care homeless services

Note It is important to note that some interventions and skills are relevant to other team members depending on specialty


GP intervention after discussing with the team and Band 7s it was agreed that given the volumeof patients and the long process for adding codes that it wasnrsquot feasible for the team toundertake coding in a timely manner As the team receives an automated weekly summary ofreferrals to the service the GP agreed with the coding lead that these would be checked foraccuracy by the Monday duty worker and faxed to the coding team who would add thehomelessness code For the other clinical codes the clinical team members were mindful tosummarise key health issues within the patient record to facilitate coding by the coding team

Overall achievement coding of homelessness status now occurs regularly which ensures thatcomplexity is highlighted within the trust data sets and that the trust receives appropriateremuneration for complex admissions

Service development 2 weekly case review recording

Problem it was realised that the team see many complex cases but were not keeping a record oflearning points service development and changes to practicewhich are recommended by the CQC

GP intervention the GP asked colleagues from primary care if they would be happy to share ablank practice review template The team adapted this to record key cases including

deaths

Cancer diagnosis

safeguarding referrals and older adults

referrals to Southwark Law Centre and

significant events

Overall achievement the team keeps a comprehensive record of reflective learning anddevelopment to support annual reports and future CQC inspections The weekly review alsohelps the team to reflect on challenges and things that went well In 2017 the deputy clinicaldirector approached the team to discuss formally reviewing deaths of homeless patients inhospital as part of regular mortality reviews As the team record these cases they were able toprovide this information and agree a protocol for referring deaths both for inpatients and thoserecently discharged (if they were informed) to the patient safety team

The presence of a pathway homeless team within an organisation does influence the approach ofhospital staff towards socially excluded groups For example it provides an opportunity to dispelmyths and stereotypes about homeless patientsrsquo health seeking behaviour thereby improvingclinical practice and outcomes Staff are willing to keep bed spaces open if a patient needs toattend housing appointments and support the homeless team to ensure a patientrsquos dignity rightsand entitlements are maintained throughout the discharge process

Case studies Patient 1 role of the GP and HousingWorker in managing frequent attendance andcomplex health issues

Patient 1 31-year-old female crack addiction known to multiple services including mental healthand police frequent attender to AampE rough sleeping and unable to sustain previousaccommodation often brought in by ambulance due to hyperglycaemia Challenging behaviouron ward and frequently self-discharged when admitted

Medical problems Type 1 diabetes on insulin with advanced complications of personalitydisorder psychiatric symptoms of crack addiction fixed beliefs about diabetes treatment efficacyand poor concordance with medication

Other problems poor engagement with primary care well known to police probable sex workingand probable learning difficulties

Activities initiated by the pathway homeless team repeatedly attempting to engage patient whenadmitted or attending AampE Advising the admitting team and medical wards of key issuesDiscussing at frequent attendersrsquo meeting and making applications to local authority foraccommodation The Housing Worker made the case for supported accommodation in a high


support womenrsquos only hostel GP assessment revealed that the patient had fixed ideas that insulinworsened diabetes and poor insight and understanding about the disease and its link to otherphysical health symptoms The GPs review of the full medical records including paper notesshowed a gradual decline in engagement with the hospital diabetes team in the preceding ten years

GP interventions meeting the psychiatrist and care coordinator to understand the full psychiatrichistory and outcomes of previous admissions and interventions Meeting the diabetes consultantto discuss the most appropriate and manageable insulin regimen Challenging negativeperceptions by hospital staff about the patientrsquos behaviour and offering insight into complexneeds and probable complex trauma

Overall achievement patient was accommodated in a high support womenrsquos only hostel whichwas close to a GP practice and outreached by the community based health inclusion teamThe GP and health inclusion team nurse arranged continence pads and appropriate mattress forthe patientrsquos needs Her ongoing care was challenging regular case conferences at the hostelenabled all staff to feel supported

Sadly this patient died of diabetes related complications In the last years of her life sheexperienced care compassion and dignity which all the teams involved felt was a considerableachievement

Role of the GP in a patient with severe mental illness and multiple health problems Patient 235-year-old woman EEA national who recently arrived in the UK This was her second admissionfor psychosis after a recent discharge from another mental health hospital in the UK

Medical problems treatment resistant psychosis Type 2 diabetes autoimmune hepatitisautoimmune vasculitis and poor concordance with treatment

Other problems denied homelessness lost all possessions could not provide details of friends inthe UK lack of trust in healthcare professionals and did not want to return to her home countrywhere she had accommodation psychiatric consultant care a community care coordinatorsocial care and welfare benefits

Activities initiated by the pathway homeless team repeatedly trying to engage the patient whodeclined to work with the team Contacted the consular office of the country of origin who put theteam in touch with family and health services and provided advice on repatriation Regularlymeeting the admitting team and handing over contact with the international health services tothem The GP assessment revealed a complex health history and abnormal blood tests thatneeded further investigation

GP interventions on review the GP felt the patientrsquos diabetes could be effectively managed withoral medication which was the patientrsquos preference and this was confirmed by the diabetesregistrar at the acute trust The GP liaised with the rheumatology team to arrange further bloodtests and advised the admitting team on risks of some antipsychotics in light of the liver diseaseThe GP spoke to the consultant and offered care planning advice and support to the ward staffaround the complex issues

Overall achievement safe medication was prescribed and the patient improved sufficiently tomake informed choices about her health and housing

The GP contributes to the teaching of junior doctors and GP trainees and has supportedthe trainees to complete research projects and clinical audits The GP has also hosted electivestudents and adhoc student placements This ensures that some form of post-graduateeducation in homeless and inclusion health issues is available to local students and trainees

Outcome data

Administrative data collected by the KHP Pathway Team supports the quality of care and value ofthe team Since the services launched the KHP pathway homeless teams have received a total of7552 referrals and undertaken 4064 patient assessments Half of the referrals received by GStTand a third at KCH and SLaM identified a history of rough sleeping while homeless hostel


dwellers accounted for 17 per cent of patients seen at GStT and 216 per cent of patients at KHPHousing status continues to be a key output measure 40 per cent of patients seen at GStT47 per cent of patients seen at Kings and 71 per cent of patients seen at SLaM have beensuccessfully resettled Pathway teams have also intervened on behalf of patients to preventevictions and tenancy breakdowns

Evidence gathered by the KHP pathway team provides further proof of the low rate of GPregistration among homeless patients Such patients have received support to register or offeredhelp to do so Tri-morbidity is common across all sites its ubiquity supports the need for seniorclinical input A snapshot of SLaM showed 77 per cent of patients had a severe mental illness55 per cent reporting alcohol or drug misuse and 14 per cent of patients having a chronicillness (diabetes asthma COPD and Epilepsy) Blood borne virus prevalence across the threetrusts is high with 5 per cent of patients diagnosed as HIV positive and between 2 and 10 per centHepatitis C positive depending on the hospital site

Interviews with other pathway homeless team GPs

Findings from ten structured interviews (seven GPs two operational managers and one nurse)illustrate the need for GPs within specialist homeless healthcare teams as well as some of theparticular challenges (Dorney-Smith 2017) It was identified that GPs offer high level clinicalthinking service and systems development and successfully manage difficult negotiations withincomplex hospital hierarches Overall GPs felt that their role is needed within pathway homelessteams but were sometimes not employed with enough sessions leaving teams without seniorclinical input for most of the week GPs highlighted the importance of the interprofessionalcharacter of the Pathway teams while also noting that the day-to-day running of services is welldelivered by senior nurses social workers or OTs GPs were concerned about the focus on beddays as an outcome measure and what this means in the context of managing complex patientswhere appropriate housing is part of the health outcome High workload in addition to a lack of ashared job description formal training competency frameworks and mentoring were identified assome of the challenges in delivering cohesive pathway homeless teams Likewise GPs wereconcerned about the increasing workload and complexity of cases and the impact this has onteam morale and the risk of burnout among team members

Discussion

The role and function of the GP is viewed as pivotal to the teamrsquos overall effectiveness The highercost of employing a GP over other senior staff such as nurses results in frequent discussionsabout their value and need GPs have expertise and skills to care for patients with multiple andcomplex needs as well as the leadership skills necessary to establish and develop in-patienthomeless services Managing expectations and articulating risks of premature dischargealongside team members while maintaining relationships is a core part of the role Given theclinical complexity of cases seen by GPs working with homeless inpatients the scope of GPscould be extended to working with homeless and excluded groups as part of intermediate caresettings or in other medical sub-specialisms in secondary care In informal interviews GPs did notconvey professional protectionism rather they discussed the value and importance ofinterprofessional teams and working across the hospital trust to achieve the best possibleoutcomes for patients The stress of managing large and often complex caseloads on GPs wasnoted by operational managers It was further suggested that mentoring or regular meetings forclinicals leads could help

The role of the GP is appreciated and valued by senior clinicians as can be seen this consultantrsquosfeedback ldquoI think it has been very helpful to have a GP involved [hellip] where there are specificmedical issues and in terms of reaching a broader medical consensusrdquo Frequent discussionsabout complex cases between GPs and specialists are evidence of the way in professionalopenness has developed over time Education and training provided to Trust staff has alsoincreased knowledge and awareness of the clinical and support needs of homeless patientsThis is evidenced by early referrals received by the pathway homeless teams incorporatinghousing and social care issues alongside health problems Staff increasingly demonstrate their


non-judgemental approach to patients by accurately describing a patientrsquos homeless situation byusing terms as habitual residence or NRPF

As the field of homeless and inclusion health is now established as a clinical subspecialty there is aneed for a framework of competence and accredited education and training for GPs and otherhealth and social care professionals specialising in this field A current project being led by the NurseFellow at Pathway and the Burdett Foundation is considering competencies for Inclusion Healthnurses which will inform how this takes shape for other professionals TwoGPs ndash one from the KHPTeam and one from the Brighton Pathway Teams ndash are pathway Fellows in Education Part of thefellowship involves collaborating with UCL to deliverer the first taught postgraduate module inhomeless and inclusion health either as a stand-alone course or part of anMSc in population health

This paper is limited to personal experience informal interviews and data from one KHP pathwayhomeless team Future research based on structured interviews or focus groups with other GPsworking in the field of inclusion health may help to identify generic roles and responsibilitieseducational needs and supervision and support requirements Data gathered from additional sitescould potentially demonstrate the need for clinically-led specialist services for excluded groups

Each and every attendance should be seen as an opportunity to engage homeless and othersocially excluded groups in a discussion about their health housing and social care needs Parityand equity of care for excluded groups continues to be an ongoing aspiration and one which GPswithin pathway homeless teams are promoting at local and national forums Under theHomelessness Reduction Act public authorities such as hospitals have a legal duty to referhomeless people or at risk of homelessness to a local housing authority How each NHS hospitaltrust delivers this is a local decision but GP-led pathway homeless teams provide a very clearexample ndash and importantly one underpinned by robust evidence ndash of how to intervene at an earlierstage to improve health and housing outcomes

References

Aldridge R Story A Hwang S Nordentoft M Luchenski S Hartwell G Tweed E Lewer DVittal Katikireddi S and Hayward A (2017) ldquoMorbidity and mortality in homeless individuals prisoners sexworkers and individuals with substance use disorders in high-income countries a systematic review andmeta-analysisrdquo The Lancet Vol 391 No 10117 pp 241-50

Aspinall PJ (2014) ldquoHidden needs identifying key vulnerable groups in data collections vulnerablemigrants gypsies and travellers homeless people and sex workersrdquo available at httpsassetspublishingservicegovukgovernmentuploadssystemuploadsattachment_datafile287805vulnerable_groups_data_collectionspdf (accessed 24 July 2018)

Begg H and Gill PS (2005) ldquoViews of general practitioners towards refugees and asylum seekers aninterview studyrdquo Diversity in Health and Social Care Vol 8 No 22 pp 299-305

Blackburn C (2003) ldquoAsylum seekers how GPs are handling life in the frontlinerdquo Doctor Vol 23 pp 23-27

Blackburn R Hayward A Cornes M McKee M Lewer D Whiteford M Menezes D Luchenski SStory A Denaxas S Tinelli M Wurie F Byng R Clark M Fuller J Gabbay M Hewett NKilmister A Manthorpe J Neale J and Aldridge R (2017) ldquoOutcomes of specialist discharge coordinationand intermediate care schemes for patients who are homeless analysis protocol for a population-basedhistorical cohortrdquo BMJ Open Vol 7 No 12 p e019282

Bramley EG Fitzpatrick S Edwards J Ford D Johnsen S Sosenko F and Watkins D (2015) ldquoHardedges mapping severe and multiple disadvantagerdquo available at httpslankellychaseorgukresourcespublicationshard-edges (accessed 24 July 2018)

Collier R (2011) ldquoBringing palliative care to the homelessrdquo CMAJ Canadian Medical Association JournalVol 183 No 6 pp 317-8

Crisis (2011) ldquoHomelessness a silent killerrdquo available at wwwcrisisorgukmedia237321crisis_homelessness_a_silent_killer_2011pdf (accessed 24 July 2018)

Davies J and Lovegrove M (2016) ldquoInclusion health education and training for health professionalsrdquoavailable at wwwgovukgovernmentuploadssystemuploadsattachment_datafile490870NIHB_-_Inclusion_Health_education__Reportpdf (accessed 24 July 2018)


Dorney-Smith S (2017) ldquoPathway challenges interviewsrdquo working paper Pathway and the Faculty forInclusion Health 11 September London

Dorney-Smith S Hewett N Khan Z and Smith R (2016) ldquoIntegrating health care for homeless peopleexperiences of the KHP pathway homeless teamrdquo British Journal of Healthcare Management Vol 22 No 4pp 215-24

Elwell-Sutton T Pawson H Bramley G Wilcox S and Watts B (2017) ldquoFactors associated with accessto care and healthcare utilization in the homeless population of Englandrdquo Journal of Public Health Vol 39No 1 pp 26-33

Fazel S Geddes JR and Kushel M (2014) ldquoThe health of homeless people in high-income countriesdescriptive epidemiology health consequences and clinical and policy recommendationsrdquo Lancet Vol 384No 9953 pp 1529-40

Fitzpatrick S Johnsen S and White M (2011) ldquoMultiple exclusion homelessness in the UK key patternsand intersectionsrdquo Social Policy and Society Vol 10 No 4 pp 510-2

Fitzpatrick S Pawson H Bramley G Wilcox S and Watts B (2018) ldquoThe homelessness monitorEngland 2018rdquo available at wwwcrisisorgukmedia238700homelessness_monitor_england_2018pdf(accessed 24 July 2018)

Ford C and Ryrie I (2000) ldquoA comprehensive package of support to facilitate the treatment of problem drugusers in primary care an evaluation of the training componentrdquo International Journal of Drug Policy Vol 11No 6 pp 387-92

Hewett N and Dorney-Smith S (2013) ldquoKingrsquos health partners and the impact of homelessness withproposed responsesrdquo available at wwwpathwayorgukpublicationspathway-research-and-service-development-publicationskings-health-partners-and-the-impact-of-homelessness-with-proposed-responses (accessed 24 July 2018)

Hewett N and Halligan A (2010) ldquoHomelessness is a healthcare issuerdquo Journal of the Royal Society ofMedicine Vol 103 No 8 pp 306-7

Hewett N Halligan A and Boyce T (2012) ldquoA general practitioner and nurse led approach to improvinghospital care for homeless peoplerdquo BMJ Vol 345 No 2 p e5999

Homeless Link (2014) ldquoThe unhealthy state of homelessness health audit resultsrdquo available atwwwhomelessorguksitesdefaultfilessite-attachmentsTheunhealthystateofhomelessnessFINALpdf(accessed 24 July 2018)

Homeless Link (2015) ldquoEvaluation of the homeless hospital discharge fundrdquo available at wwwhomelessorguksitesdefaultfilessite-attachmentsEvaluationoftheHomelessHospitalDischargeFundFINALpdf (accessed24 July 2018)

Homeless Link (2017) ldquoSupport for single homeless people in England annual review 2017rdquo available at wwwhomelessorguksitesdefaultfilessite-attachmentsAnnualReview2017_0pdf (accessed 24 July 2018)

Johnson DR Ziersch AM and Burgess T (2008) ldquoI donrsquot think general practice should be the front lineexperiences of general practitioners working with refugees in South Australiardquo Australia and New ZealandHealth Policy Vol 5 No 1 p 20

Levitas R Pantazis C Fahmy E Gordon D Lloyd E and Patsios D (2007) ldquoThe multi-dimensionalanalysis of social exclusionrdquo available at wwwbrisacukpovertydownloadssocialexclusionmultidimensionalpdf (accessed 24 July 2018)

Luchenski S Maguire N Aldridge R Hayward A Story A Perri P Withers J Clint S Fitzpatrick Sand Hewett N (2017) ldquoWhat works in inclusion health overview of effective interventions for marginalisedand excluded populationsrdquo The Lancet Vol 391 No 10117 pp 266-80

Mann C Hewett N and Dacre J (2015) ldquoInclusion health clinical audit 2015-16 pilot report ndash patient auditrdquoavailable at wwwrcemacukdocsQI20+20Clinical20Audit22a20Organisational20report20-20how20A+E20services20are20organisedpdf (accessed 24 July 2018)

Manthorpe J Cornes M OrsquoHalloran S and Joly L (2015) ldquoMultiple exclusion homelessness thepreventive role of social workrdquo British Journal of Social Work Vol 45 No 2 pp 587-99

Mathie H (2012) ldquoImproving hospital admission and discharge for people who are homelessrdquo available atwwwhomelessorguksitesdefaultfilessite-attachmentsHOSPITAL_ADMISSION_AND_DISCHARGE_REPORTdocpdf (accessed 24 July 2018)


Mehet D and Ollason M (2015) ldquoHealth services for homeless people programmerdquo available at httphealthylondonorghlp-archivesitesdefaultfilesHealthservicesforhomelesspeopleinLondon-Caseforactionpdf (accessed 24 July 2018)

Ministry of Housing communities and Local Government (2017) ldquoRough sleeping statisticsrdquo available athttpsassetspublishingservicegovukgovernmentuploadssystemuploadsattachment_datafile682001Rough_Sleeping_Autumn_2017_Statistical_Release_-_revisedpdf (accessed 24 July 2018)

Office of the Chief Analyst (2010) ldquoHealthcare for single homeless peoplerdquo Department of Healthavailable at httpwebarchivenationalarchivesgovuk20130123201505httpwwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_114250 (accessed 24 July 2018)

Rae BE and Rees S (2015) ldquoThe perceptions of homeless people regarding their healthcare needs andexperiences of receiving health carerdquo Journal of Advanced Nursing Vol 71 No 9 pp 2096-107

Story A Aldridge R Gray T Burridge S and Hayward A (2014) ldquoInfluenza vaccination inverse careand homelessness cross-sectional survey of eligibility and uptake during the 201112 season in LondonrdquoBMC Public Health Vol 14 No 1 p 44

Stringfellow EJ Kim TW Pollio DE and Kertesz SG (2015) ldquoPrimary care provider experience andsocial support among homeless-experienced persons with tri-morbidityrdquo Addiction Science amp ClinicalPractice Vol 10 No Suppl 1 p A64

Thomas B (2012) ldquoHomelessness kills an analysis of the mortality of homeless people in early twenty-firstcentury Englandrdquo available at wwwcrisisorguk (accessed 24 July 2018)


Zana Khan can be contacted at zanakhanhotmailcouk



Hospital collaboration with a Housing Firstprogram to improve health outcomes forpeople experiencing homelessness

Lisa Wood Nicholas JR Wood Shannen Vallesi Amanda Stafford Andrew Davies andCraig Cumming

Abstract

Purpose ndash Homelessness is a colossal issue precipitated by a wide array of social determinants andmirrored in substantial health disparities and a revolving hospital door Connecting people to safe and securehousing needs to be part of the health system response The paper aims to discuss these issuesDesignmethodologyapproach ndash This mixed-methods paper presents emerging findings from thecollaboration between an inner city hospital a specialist homeless medicine GP service and WesternAustraliarsquos inaugural Housing First collective impact project (50 Lives 50 Homes) in Perth This paper drawson data from hospitals homelessness community services and general practiceFindings ndash This collaboration has facilitated hospital identification and referral of vulnerable rough sleepers to theHousing First project and connected those housed to aGP and after hours nursing support For a cohort (nfrac14 44)housed now for at least 12 months significant reductions in hospital use and associated costs were observedResearch limitationsimplications ndash While the observed reductions in hospital use in the year followinghousing are based on a small cohort this data and the case studies presented demonstrate the power ofcare coordinated across hospital and community in this complex cohortPractical implications ndash This model of collaboration between a hospital and a Housing First project can notonly improve discharge outcomes and re-admission in the shorter term but can also contribute to endinghomelessness which is itself a social determinant of poor healthOriginalityvalue ndash Coordinated care between hospitals and programmes to house people who arehomeless can significantly reduce hospital use and healthcare costs and provides hospitals with theopportunity to contribute to more systemic solutions to ending homelessness

Keywords Social determinants of health Healthcare Homelessness Primary care Emergency departmentHospital discharge


1 Background

11 Health and homelessness are intertwined

On nearly any measure of health inequality people experiencing homelessness are vastlyover-represented (Luchenski et al 2018) and the compounding reciprocity of the relationshipbetween homelessness and health has been observed globally (Wood et al 2016) UK datareports an average life expectancy of 47 years among people who are homeless and multiplecomplex morbidities are common (Perry and Craig 2015) Health conditions that are moreprevalent in homeless populations include psychiatric illness substance use chronic diseasemusculoskeletal disorders poor oral health and infectious diseases such as tuberculosishepatitis C and HIV infection (Aldridge et al 2018 Perry and Craig 2015)

The homeless population has disproportionately high healthcare use and are far more likely toaccess acute health services experience multiple morbidities and die prematurely (Fitzpatrick-Lewiset al 2011 Kushel et al 2002) Constellations of trauma poverty substance misuse educational

copy Lisa Wood Nicholas JRWood Shannen Vallesi AmandaStafford Andrew Davies and CraigCumming Published by EmeraldPublishing Limited This article ispublished under the CreativeCommons Attribution (CC BY 40)licence Anyone may reproducedistribute translate and createderivative works of this article (forboth commercial and non-commercial purposes) subject tofull attribution to the originalpublication and authors The fullterms of this licence may be seenat httpcreativecommonsorglicencesby40legalcode

The authors would like to thankMisty Towers AdministrativeAssistant for the Royal PerthHospital Homeless Team for herrole in extracting case study datathe RPH business intelligence unitfor assisting with compiling linkeddata Leah Watkins at RuahCommunity Services for herexpertise and information acrossof a variety of topics and finallyMatthew Tucson and Kevin Murrayfrom School of Population andGlobal Health at the University ofWestern Australia for theirassistance in managing andextracting data

(Information about the authorscan be found at the end of thisarticle)

DOI 101108HCS-09-2018-0023 VOL 22 NO 1 2019 pp 27-39 Emerald Publishing Limited ISSN 1460-8790 j HOUSING CARE AND SUPPORT j PAGE 27

disadvantage unemployment domestic violence and social disconnection are common(Hwang et al 2009 Fowler et al 2009) and this imbalance of social determinants fuelsdeteriorating health outcomes and persistent use of acute healthcare

People experiencing homelessness are less likely to seek primary or preventative health servicesand so present later with a diagnosis of greater severity or with avoidable complications (Mooreet al 2007 Rieke et al 2015) There are raft of impediments to healthcare access for people whoare homeless At the personal level just meeting basic day-to-day needs for food and a place tosleep is challenging and health is often neglected until crisis point is reached (Wise and Phillips2013) Poor health itself can be a barrier to accessing healthcare particularly among people withmental illness addictions cognitive impairment or mobility limitations (Davies and Wood 2018)Experiences of trauma are pervasive among homeless population and this coupled with stigma andpast negative experiences of the health system can render people wary of seeking help (Davies andWood 2018) There are also practical barriers to health service access including lack of transportand not being contactable for appointment reminders (Davies and Wood 2018)

As articulated by Marmot (2015) it is futile to treat homeless patients in hospitals beforedischarging them back to the abysmal social conditions that made them sick in the first place todo so perpetuates a revolving door between the hospital and the street or between the hospitaland precarious housing

12 Housing as healthcare

Mounting evidence supports the argument that re-housing people experiencing homeless is apowerful healthcare intervention (Stafford andWood 2017) The Housing First approach originated inNew York (Tsemberis and Eisenberg 2000) and as the name implies advocates that long-termhousing is the essential first step that then provides stability that enables other complex medical andpsychosocial issues to be addressed (Johnson et al 2010 Mackelprang et al 2014) The emphasisis on housing people rapidly with no pre-conditions and providing support services in conjunctionwith the long-term housing to support people exiting homelessness to sustain tenancies andaddress other issues (Johnson et al 2010) There are now many Housing First programmes acrossthe USA and Canada (Woodhall-Melnik and Dunn 2016) and a growing number across the globeincluding Finland (Busch-Geertsema 2013) Italy (Lancione et al 2018) and Australia (Conroy et al2014 Wood et al 2017 500 Lives 500 Homes 2016) Around the world no two Housing Firstprogrammes are the same with iterations reflecting variations in programme funding and partnersalong with adaptation to cultural social and political contexts (Lancione et al 2018) Housing Firstprogrammes have demonstrated significant reductions in emergency department (ED) presentationsand hospital admissions (DeSilva et al 2011 Russolillo et al 2014 Mackelprang et al 2014Larimer et al 2009 Debra et al 2013) A 2011 review of the Housing First approach emphasised thebenefits when housing was secured as a part of hospital discharge for homeless people particularlythose with severe mental illness andor substance use issues (Fitzpatrick-Lewis et al 2011)

Whilst reduced hospital use has been demonstrated to be a Housing First outcome there isscant literature describing the converse how hospitals can engage in Housing First programmesto connect patients to housing and social support and reduce the likelihood of repeatre-admissions This paper demonstrates how a collaboration between a Housing Firstprogramme a major city hospital and a Homeless Medicine GP service is improving the healthand housing outcomes for vulnerable rough sleepers The interdisciplinary and inter-servicecollaboration between these three providers affords a seamless continuity of care throughhospital general practice and the community

13 Integrating health into a Housing First collaboration

The three services involved in this intervention are

1 A ldquoHousing Firstrdquo programme for Perthrsquos most chronic and complex rough sleepers

Perthrsquos inaugural Housing First Programme the 50 Lives 50 Homes (50L50H) Project is amulti-agency collaboration targeting Perthrsquos most vulnerable rough sleepers (Stafford and Wood2017) The project is based on overseas and interstate models (adapted to the local context) and


was launched in July 2015 with small seed funding from two government departments beforereceiving philanthropic support for the next three years of operation The diverse range ofpartners (nfrac14 28) includes government departments community housing organisationsspecialist aboriginal services community health and support organisations (Stafford andWood 2017) The 50L50H project uses a validated triage tool the Vulnerability Index ndash ServicePrioritisation Decision Assistance Tool (VI-SPDAT) to assess key mortality risk indicators that areprevalent in people experiencing long-term homeless (Hwang et al 1998) Since July 2015147 people have been housed in 109 homes with 87 per cent sustaining their tenancy at oneyear (Vallesi et al 2018) The type of housing provided is dependent on individual need andcircumstance such as access and location to services and transport disability (ie ground floorapartments vs high-level apartments accessible via stairs only) living arrangement (ie partnerschildren) and if additional support is required

2 A specialist homeless medicine general practice

Homeless Healthcare (HHC) is a multi-site GP practice that aims to bring primary healthcareservices to places where homeless people feel comfortable There are clinics in drop in centrestransitional accommodation services a drug and alcohol therapeutic community and a GPsurgery in a central metropolitan location Nurses run street outreach clinics and provide supportto those who have been re-housed under 50L50H Staff work closely with the majorhomelessness services (NGOs) and prioritise housing as part of care

3 A hospital Homeless Team

Australiarsquos first Homeless Medicine GP in-reach programme started in June 2016 at Perthrsquos innercity hospital Royal Perth Hospital (RPH) It serves a large proportion of Perthrsquos homelesscommunity especially those who are street present (Gazey et al 2018) with 1 in 24 RPH EDpatients being recorded as of ldquono fixed addressrdquo (NFA) upon presentation RPHrsquos HomelessTeam is based on the UK Pathway model (Hewett et al 2016) and is a partnership betweenRPH Ruah Community Services and HHC The hospital-based Homeless Team consists ofa HHC GP HHC Nurse an RPH Consultant Clinician and a community services caseworkerIt works with the homeless patients in RPH to assist them with a range of issues such astheir inpatient treatment discharge planning and linking to housing and support servicesThe Homeless Team members are also active participants in the 50L50H project the RoughSleepers Working Group and some members also sit on the 50L50H Steering Group

2 Methods

21 Data sources

This paper draws on the following data sets the VI-SPDAT database held by Ruah CommunityServices the Perth Metropolitan Hospital database (WebPAS) HHC GPrsquos clinical database (BestPractice) administrative hospital and ED data and observational data from community caseworkers engagedwith 50L50H clients These data sources were used to inform the six case studies

VI-SPDAT data Entry into the 50L50H project requires that a homeless individual or family hasbeen assessed as being ldquohighly vulnerablerdquo using the VI-SPDAT (score ⩾ 10) The Tool is acombination of the Vulnerability Index (VI) and the Service Prioritization Decision Assistance Tool(SPDAT) and is used widely in the USA Canada (OrgCode 2015) and Australia (Flatau et al 2018)to assess vulnerability and the level of assistance from services required to exit homelessnessThe tool collects self-report information across a range of domains including history of housing andhomelessness health healthcare utilisation police and justice system contacts and wellness(US Department of Housing and Urban Development 2014) The VI-SPDATwas used during PerthRegistry Weeks the street homelessness snapshot surveys carried out in 2012 2014 and 2016(Flatau et al 2018) and continues to be administered by homelessness community services HHCstaff at their clinics and the RPH Homeless Team All completed surveys are scored by RuahCommunity Services While the VI-SPDAT is used by 50L50H to prioritise the most vulnerablerough sleepers for rapid housing and support it does not always describe the full extent ofvulnerability This is most commonly seen with severe mental health issues (eg individuals whohave active psychosis may be unable to comprehend survey questions)


Case studies Case studies are used in this paper to provide examples of the four types ofcollaboration described Five short case studies have been compiled by triangulating several datasources hospital service utilisation data extracted by the RPH Homeless Team from the Perthmetropolitan hospital patient database (TOPAS) VI-SPDAT data HHC medical records andclinical staff observations

Administrative hospital data Identifying information (eg given names surnames date of birth) wasprovided to the business intelligence unit (BIU) at WA Health for all 50L50H clients along with aunique study ID for each individual to enable the administrative data to be provided without namesor other identifying information Administrative hospital data included ED presentations hospitaladmissions and outpatient service utilisation for all 50L50H clients for the period 1 January 2013ndash30 April 2018 Data were obtained for four hospitals ndash RPH (which sees the greatest proportion ofhomeless patients in Perth) and three other metropolitan hospitals within the East MetropolitanHealth Service Catchment (Kalamunda Bentley and ArmadaleKelmscott) The administrative datawere provided to a different researcher who did not have access to the identifying variables originallyprovided to the BIU to ensure participants would not be re-identified by the research team

22 Analysis

We identified individuals who had at least 12 months follow-up after being housed through50L50H We restricted our analyses to this group so that we could compare the periods of12 months pre- and post-housing for changes in service use Hospital admission and EDpresentation data were analysed for the pre- and post-housing periods to produce counts forpresentations admissions and to calculate the number of hospital days admitted both at a groupand individual level Due to the data being heavily skewed non-parametric statistical methodswere used to test for group differences in ED presentations and hospital admissions between theperiods before and after housing Hospital admissions for chronic kidney disease dialysis andchemotherapy were excluded from the analyses as these are generally planned single-dayadmissions for tertiary care of chronic conditions that are often managed in a hospital settinghowever are likely not associated with an individualrsquos housing status while the focus of this studyis largely unplanned admissions for preventable conditions that require acute care Estimatedcosts for hospital presentations and admissions have been calculated using the IndependentHospital Pricing Authority (IHPA) Round 20 Cost Report (IHPA 2018) which gives the WesternAustralian average cost for an ED presentation and inpatient days

23 Ethics approval

This paper is based on findings from two inter-related research projects The approval to conductthe first research project was granted by the RPH Human Research Ethics Committee (HREC) on26May 2017 (Reference No RGS0000000075) with reciprocal approval granted by the University ofWestern Australia HREC on 10 October 2017 (Reference RA4204045) The approval to conductthe evaluation of the 50L50H project was granted by the University of Western Australian HumanResearch Ethics Committee on 20 January 2017 (Reference No RA418813)

3 Results

This paper first describes four key domains of collaboration between the hospital HHC and the50L50H project

1 identification of patients in RPH who are homeless and assessment of vulnerability

2 referral of high acuity homeless patients to the 50L50H Rough Sleepers Working Group

3 connecting discharged patients to primary care and follow-up support in the community and

4 communication between the Housing First partners to prevent clients falling through the cracks

Second the paper presents preliminary findings relating to changes in patterns of hospital useamongst 50L50H clients housed for 12 months or more


31 Identification of patients who are homeless and assessment of vulnerability

Generally homeless people are more likely to frequent an inner city hospital as they are close towhere homelessness services are concentrated The Homeless Team at RPH uses multiplemethods to find the homeless clients in the hospital eg daily listings of NFA patients andattending wards with frequent admission of homeless patients As part of the assessment ofrough sleepers the VI-SPAT is administered if this has not already occurred

The evaluation of the Homeless Teamrsquos first 18 months of operation found that 64 per cent of clientswho had VI-SPDAT screening had a vulnerability score ⩾10 (Gazey et al 2018) This confirms theimportant role of the hospital in identifying highly vulnerable rough sleepers who have not previouslyengaged with community homelessness services but present to hospital when unwell or injured

For the 50L50H project the use of the VI-SPDAT at RPH has identified many people with highvulnerability that may otherwise have remained undetected and homeless on the streets As theVI-SPDAT is automatically uploaded to a database monitored by the 50L50H team patients whohave scored 10 or more in the VI-SPDAT at the hospital are flagged as eligible for the 50L50Hproject An example of this can be seen in Case Study 1 below where a male who had beenhomeless for 26 years completed the VI-SDAT survey at in the ED at RPH and whose score of 14indicated high vulnerability

Case study 1 ndash 26 years on the street

Background A man in his late fifties had spent 26 years rough sleeping under a suburban bridge withvarious health issues including schizophrenia lung and liver disease In 2015 he started to presentfrequently to hospital EDs due to increasingly severe back pain which limited walking to several metersand left him wheelchair bound He asked for assistance with housing and medical issues but wasgenerally discharged rapidly from ED as ldquonot having an acute problemrdquo In one of his hospital dischargesummaries it indicated that he had been given a taxi voucher to return to the bridge

Intervention In mid-2016 he was seen by the RPH Homeless Team and completed a VI-SPDAT scoring14 indicating high vulnerability and eligibility for the 50L50H project He required intensive input from his50L50H caseworker to find suitable accommodation as he required supported care and was bouncedbetween disability and aged care services Inmid-2017 hewas successfully housed in an aged care hostel

32 Referral of patients to the 50L50H rough sleepers working group

Some clients only engage with services for the first time when hospitalised with injury orillness Contacts with the hospital can often be the portal through which the road to housing andrecovery begins The Homeless Team at RPH and HHC GP work directly with some of the mostvulnerable rough sleepers in Perth By combining clinical information with data from the VI-SPDATthe team is able to identify people with high need for a Housing First intervention and makerecommendations concerning the specific types of housing and support for the patientsrsquo needsThe effectiveness of this approach is summarised by the 50L50H project manager

The RPH Homeless Team is very active in the 50 Lives 50 Homes rough sleepers working group andthere is enormous mutual benefit for both the hospital and for the homeless sector in Perth Some of themost vulnerable rough sleepers in Perth have been brought to our attention by the RPHHomeless Teamand we have been able to prioritise them for support and housing (50L50H Project Manager)

In some cases a VI-SPDAT score below 10 may not adequately reflect the level of vulnerability oracute need of a particular patient In the case study below the patient was severely psychotic atthe time of VI-SPDAT completion and the computed score of 3 was a stark mismatch to his levelof need Advocacy by the RPH hospital team and HHC played a critical role in the intensive mentalhealthcare he received and in his subsequent housing through 50L50H

Case study 2 ndash advocacy sorely needed

Background A man in his mid-forties with a diagnosis of schizophrenia dating back to the 1990s andhad historically very little contact with psychiatric services By 2009 he was street homeless and aftertwo brief psychiatric admissions was placed in a psychiatric hostel but soon returned to the streetsFor nearly three years there is no record of any psychiatric care He presented to ED sporadically in2014-2015 with complaints such as sore feet but although he was noted to be living on the streets andschizophrenic he was discharged back to the street each time


Intervention He was first detected by HHC Street Health outreach in early December 2015 with a largeabscess on his back Initially reluctant to accept treatment the abscess worsened and he agreed to beadmitted to RPH ED During this admission he underwent psychiatric review and subsequentlyreceived his first depot injection of antipsychotic medication in three years The psychiatric teamdischarged him with an arrangement for GP follow up with HHC for voluntary treatment with depotantipsychotic medication However he refused any further medication and HHC actively advocated foran admission to enable his schizophrenia to be treated In late December 2015 he was admitted to aMental Health Unit where he spent five months (141 days) receiving treatment including antipsychoticmedication Over these months his psychosis slowly resolved and was discharged to a supportedpsychiatric hostel It emerged that he had a wife and children from who he had become estranged dueto his illness Through 50L50H he secured a place in supported accommodation for people withchronic mental illness and has now resided there for two years

33 Connecting patients to primary care and follow-up support in the community

The RPH Homeless Teamrsquos composition of community caseworker HHC nurse HHC GP andRPH ED consultant directly connects hospitalised individuals experiencing homelessness with arange of community health and homelessness services This includes follow up with HHCrsquos GPclinics for comprehensive primary and preventative healthcare or another GP of their choice(eg Aboriginal-specific health services) Clients of the 50L50H project are also eligible for supportby an After Hours Support Service (AHSS) This team consists of a HHC nurse and a RuahCommunity Services caseworker who work evenings weekends and public holidays to provideextended hours of support at clientsrsquo homes

The combination of nursing and social care is particularly effective for people with complex issues orwho have experienced long-term homelessness (Stafford andWood 2017) The early stages of beinghoused can be immensely challenging with poor physical andmental health adding to the concomitantstress of adjusting to a very different way of life The AHSS teamrsquos role in maintaining regular contactwith re-housed clients is a key intervention for supporting client health and wellbeing The AHSScoordinates closely with each clientrsquos primary caseworker to streamline care and case workers canrequest changes to AHSS intervention (eg increasing the frequency of visits during times of difficulty)

As shown in Case Study 3 the support provided by the AHSS has a holistic focus on improving healthwellbeing and housing outcomes based around the individual clientrsquos social determinants of health

Case study 3 ndash After-hours health and psychosocial support once housed

Background An Aboriginal woman in her mid-forties came into contact with HHC in early 2016 andwas assessed as having a high level of vulnerability on the VI-SPDAT (score of 10) Her homelessnesswas associated with a history of domestic violence and troubled family circumstances and she had araft of health issues including anxiety and depression a skin cancer that led to a limb amputation andalcohol and drug use

Intervention She was housed through 50L50H relatively quickly Regular support from the AHSS teamin the form of home visits and telephone calls has contributed to significant improvements in themanagement of the clientrsquos physical and mental health issues In her own words

They come out here the outreach They come here and see if Irsquomokay even if itrsquos for a chat sometimesbecause Irsquod get very anxious [hellip]

The broad social determinants outlook taken by the AHSS team and 50L50H is evident in the waythat the team has encouraged her involvement in art classes and provided transport to aparenting course as a pathway to regaining custody of her youngest child

The close collaboration and shared staffing across AHSS HHC and the RPH Homeless Teamenhances the continuity of care for 50L50H clients Not only is it reassuring for clients to seefamiliar staff in unfamiliar places like RPH it facilitates seamless pathways of care across thehospital GP practice and community services (see Case study 4)

Case study 4 ndash benefits of staff working across hospital and community setting

Background A man in his mid-forties was housed by 50L50H in March 2017 after nearly four years ofintermittent homelessness He has a traumatic brain injury from a fall and experiences seizures but isfearful of hospitals and medical professionals and is reluctant to take medication


Intervention The AHSS team visits this client weekly and has been supporting him with to theconsequences of his brain injury and encouraging him to take his seizure medication The AHSS nursewho visits him weekly also does ward rounds with the Homeless Team at RPH so is a familiarface when the client recently presented to hospital and was able to follow up with him at homefollowing discharge

34 Communication between the Housing First partners to prevent clients ldquofalling throughthe cracksrdquo

One of the challenges in the homelessness sector is the difficulty of finding and maintainingcontact with people who are rough sleeping This can be an issue for hospitals when forexample people do not attend outpatient appointments or lapse in treatment compliance It canalso be an issue for homelessness services when clients disappear off the radar A significantbenefit of 50L50Hrsquos highly collaborative way of working for which client consent is obtained hasbeen the ability of the partners involved to share meaningful information about clients (Vallesiet al 2018) This cooperation enables closer monitoring and understanding of client issuesfaster andmore effective responses to needs and the ability to rapidly engage multiple agencies incollective solutions to complex client problems

Case study 5 ndash communication between hospital and 50L50H collaborators to improve continuityof client care

Background A male in his late sixties has been homeless for well over 40 years living most of the timeon the streets He has a long history of substance use disorder and schizophrenia but had neithersought nor received much treatment for these In one recent instance this client had presented to EDwith a large head wound but ending up leaving untreated and against medical advice

Intervention The RPH Homeless Team was able to liaise with outreach workers linked to the 50L50Hproject to quickly identify the whereabouts of the client and get him to return to hospital The HomelessTeam were then able to secure an aged-care assessment for the patient leading to his admission to anaged-care facility Sadly this arrangement didnrsquot last and shortly after returning to the streets he wasdiagnosed with late stage cancer Through the advocacy of the RPH Homeless Team was able to enterpalliative care until he passed away The alternative would have been that he died likely alone on the streets

35 Potential to reduce hospital use among Housing First clients

As part of the larger 50L50H evaluation the hospital use of participating clients is being trackedover time The working hypothesis is that rates of ED presentations and unplanned hospitaladmissions amongst 50L50H clients will decline through the coupling of housing psychosocialsupport and access to primary healthcare This paper looks at the subset of clients who had beenhoused for 12 months or longer as at 30 April 2017 (nfrac14 44) exploring changes in hospital use12 months prior to and 12 months post the date they were housed by 50L50H (see Table I)

ED presentations The proportion of clients presenting to ED reduced by a quarter (256 per cent)in the 12 months following being housed The average number of ED presentations perclient dropped from 46 prior to housing to 20 afterwards reflecting a significant reduction(minus568 per cent) in the total number of ED presentations in this subgroup for the 12 monthsfollowing housing At the individual level there was a reduction in ED presentations fortwo-thirds of the group (66 per cent)

Inpatient admissions There was also a significant decrease in inpatient admissions among clientswho were housed for 12 months or more Half of this group had inpatient admissions in the12 months prior to housing compared with 32 per cent in the 12 months following housingThe total number of days stayed as an inpatient decreased from 217 days in the 12 months priorto housing to 101 in the 12 months after This equates to a 53 per cent reduction inpatient daysand an average reduction in the length of stay of 88 inpatient days

Representations post-discharge With respect to clients re-presenting to the ED in the periodafter release from hospital there were reductions of 625 and 711 per cent for re-presentationswithin 7 days and 30 days of release respectively

Cost savings to health system The estimated cost saving to the health system associated withthe observed reductions in ED presentations for this subset of 44 clients in the year following


housing was $88740 whilst the substantial reduction in inpatient days equated to a saving of$315288 The total saving associated with these reductions was $404028 across the44 clients (over $9000 per client in 12 months alone) It should be noted that these figures arebased on only four EMHS hospitals It has been estimated that at least 30 per cent of 50L50Hclients are also presenting at other hospital across Perth so the true cost on the health systemis likely to be underestimated

4 Discussion

Inpatient hospital healthcare treats acute episodes of injury and illness however the health ofhomeless people is characterised by chronic illness which is best managed in GP or outpatientclinics Unfortunately homeless people struggle to access these services instead waiting untillate in the course of their illness and present to hospital when acutely unwell They are oftendischarged whilst still too unwell to survive on the streets resulting in a further deterioration inhealth and representation to hospital At the core of the poor health of homeless people is theabsence of a safe and secure house in which to live therefore housing has to be part of the healthsolution Although housing has not traditionally been seen as ldquothe hospitalrsquos jobrdquo and in thecurrent climate of escalating healthcare costs and the need to deliver cost-effective healthinterventions we argue that programmes facilitating the linking of homeless individuals withprimary care and other services to address the social determinants of health (including housing)are integral to a just and economically rational healthcare system

In this paper we have described how a major city hospital frequented by people who arehomeless can collaborate with a Housing First programme and a community-based GP tosimultaneously yield positive health and housing outcomes for societyrsquos most vulnerable roughsleepers The paper is intentionally descriptive as whilst reduced hospital use has been

Table I Changes in ED presentations and inpatient admissions pre- and post-housing ( for those housed 12 months or more)

Pre-housing (nfrac14 44) Post-housing (nfrac14 44) Change observed post-housing

ED presentationsNumber presenting to ED 31 (70) 23 (52) minus258Total ED presentations 204 88 minus568Mean (SD) per person 46 (68) 20 (44) po0001Range 0ndash26 0ndash25

ED representations after discharged from EDRe-presentations to ED within 7 days 24 9 minus625Re-presentations to ED within 30 days 38 11 minus711

Inpatient admissionsNumber of people admitted 22 (50) 14 (32) minus364Total inpatient admissions 76 37 minus513Mean (SD) per person 17 (27) 08 (24) pfrac140002Range 0ndash13 0ndash15

Inpatient days (LOS)Total inpatient days 217 101 minus535Mean (SD) days per person 49 (110) 23 (50) pfrac140029Range in days 0ndash64 0ndash22

Associated health system costsED presentation cost $156060 $67320 minus$88740Inpatient days cost $589806 $274518 minus$315288Total health service use cost $745866 $341838 minus$404028Average cost per client (nfrac14 44) $16952 $7769 minus$9182

Notes Costs are based on the latest Independent Hospital Pricing Authority (Round 20) figures for the 2015ndash2016 financial year for WA ED $765 perED presentation $2718 per day admitted to inpatient ward Wilcoxon signed-rank test was usedSource Hospital data from East Metropolitan Catchment area (RPH Bentley ArmadaleKelmscott Kalamunda) only


documented in a number of Housing First studies (DeSilva et al 2011 Russolillo et al 2014Mackelprang et al 2014 Larimer et al 2009 Debra et al 2013) there is a paucity of papersdiscussing the integral role that a hospital can play as an active Housing First partner

The RPH Homeless Team is Australiarsquos first GP in-reach programme for homeless people modelledon the Pathway model that now exists across 11 hospitals in the UK (Pathway UK 2018)The experience of the RPH Homeless Team illustrates the potential of this approach locally bydemonstrably improving the health and healthcare costs in one of our most costly complex andmarginalised patient cohorts We demonstrate that using a Housing First approach of direct access tolong-term housing coupled with GP healthcare and support services including an after-hours supportservice maintains clients in housing and reduces hospital re-admissions and health expenditure

The key interventions for a patient experiencing homelessness are access to affordable stableaccommodation and community support to maintain their tenancy whilst they deal withunderlying personal and medical issues including mental illness and substance use The type ofhospital homeless team described in this paper is an efficient model for facilitating this process aGP with deep roots in the community homelessness services sector and partnerships withtertiary hospitals bringing relevant expertise to patients at the hospital bedside thereby starting aprocess that will continue in the community after hospital discharge

This paper focusses on clients of the 50L50H project which specifically targets rough sleepers whorequire the highest levels of intervention The 50L50H project recognises the extreme need of thiscohort and in prioritising service provision to the most vulnerable individuals avoids the temptationto help the ldquoeasiestrdquo clients first thereby generating more ldquosuccess storiesrdquo The overall results of50L50H are therefore impressive with 87 per cent of all housed 50L50H clients retaining theirtenancy one year after being housed (Vallesi et al 2018) We suggest that the synergism betweenhospital GP practice and community services is responsible for these excellent retention rates

The examples of collaboration in action described in this paper can be readily adapted to othersettings both within the health sector and more widely For hospitals without a dedicatedhomeless team the social work department or staff working in areas where people who arehomeless are over-represented (such as ED) could broker ties with programmes and servicesthat can assist people to obtain stable housing Outside of the hospital setting there are otherhealth services where people who are homeless may be more likely to present including nocharge drop-in health clinics in disadvantaged areas and alcohol and drug services Beyond thehealth and homeless sectors 50L50H has shown that there is a wide array of organisationswilling to partner in a collective impact intervention to tackle homelessness with 28 participatinggovernment and non-government agencies spanning police housing mental health Indigenousoutreach and social services (Wood et al 2017)

The changes in hospital use observed among 50L50H clients to date has also helped to addweight to calls to continue and expand this Housing First programme in WA with the recentlyreleased WA 10-year Strategy to End homelessness advocating for the Housing First approachto be rolled out across the State (Reynolds et al 2018)

The concept of a hospital widening the scope of interventions to include addressing socialdeterminants of health could be applied to a wider variety of hospital patients than thoseexperiencing rough sleeping Rough sleepers demonstrate the most extreme examples of poorhealth driven by adverse social circumstances however there are other groups whose healthwould benefit from similar interventions including the range of more marginalised groupidentified in the recent Lancet paper on inclusion health (Luchenski et al 2018) As thechallenges of managing almost any illness or injury are compounded by the existence of povertyandor social exclusion hospitals can circumvent multiple attendances by systematicallyidentifying at-risk patients and referring them to community-based interventions that might startat the hospital bedside

On a larger scale governments can address social determinants of health to improve the health andwellbeing of the community at a lower cost In terms of healthcare this involves shifting funding out oflow value care into higher value lower cost care in prevention primary care and community-basedprogrammes Access to affordable decent housing is another pillar of cost- effective social change


41 Limitations

Whilst the case studies yield valuable insights they cannot be generalised to the broaderpopulation of people experiencing homelessness The cases presented however representcommon themes and issues The hospital data presented are limited to four hospitals only andgiven the mobility of many rough sleepers this is an underestimate rather than overestimateoverall hospital usage As 50L50H is only in its second year the sample size of clients housed forat least 12 months is small (nfrac14 44) but longitudinal comparison of hospital use before and afterhousing is nonetheless indicative of the potential cost savings to the health system that can arisewhen people are housed and provided with wrap-around support

42 Implications for future research

There are a number of implications for future research with just three suggested here

1 Around the globe a recurrent catchcry in policy and research discourse on homelessness isthat greater collaboration across sectors is vital but published studies to date tend to focusprimarily on outcomes (health or housing) observed and the ldquohow tordquo of achieving effectivecollaboration across sectors as disparate as health housing homelessness justice andwelfare is often not elucidated We have sought to demonstrate in this paper the benefits ofmapping the collaboration processes and impacts of interventions that transcend health andhomelessness silos and more research of this kind could accelerate the sharing of learningsbetween countries and programmes

2 Notwithstanding the moral and human rights imperative to reduce health disparities andhomelessness economic pragmatism is a powerful driver of policy and funding decisions infiscally strained health systems (Stafford andWood 2017) It is critical therefore that we build theevidence base for hospitals and other health organisation partnerships with interventions such asHousing First that can yield economic savings to health and other government portfolios whilststill addressing the underlying social determinants of health and prioritising person-centred care

3 A recent paper in The Lancet (Aldridge et al 2018) highlighted the critical need to monitorhow well health and social policy addresses the needs of societies most marginalisedpopulations The authors went on to note that ldquosuch initiatives need to be supported byinformation systems that can provide data for continuing advocacy guide servicedevelopment and monitor the health of marginalised populations over timerdquo (Aldridgeet al 2018 p 8) We echo this call emphatically In this paper we have shared some of ouremerging findings from the linking of administrative hospital homeless sector and case notedata but this has been a challenging and time consuming process Mainstream health datasystems tend not to capture psycho-social or homeless history data whilst homelessnessservices tend not to use robust health measures and there is a need for research andinvestment to build information systems that enable us to better monitor the effectiveness ofinterventions in this space Data pertaining to people who are homeless are also often messyfrom our experience ndash people do not have an address to record they may not know theirbirth date and aliases are sometime used when people are wary of disclosing identity Weencourage other researchers to persist despite these challenges however and to publishand share learnings about how data challenges can be overcome

5 Conclusions

While homelessness is readily recognised as a social and humanitarian issue it is also a majorfinancial issue for government services such as health justice police child protection and socialwelfare A hospitalrsquos job is clearly to deliver healthcare However the factors determiningwhether that healthcare was effective ( for outcome and for money spent) often lie outside ofthe hospitalrsquos usual remit Neither reducing barriers to healthcare access (such as free of chargehealthcare at point of delivery) nor having ldquostate of the artrdquo healthcare systems can overcome thehealth inequality of the socially disadvantaged

Chronic rough sleepers are arguably the most marginalised group in society and seen as toocomplex to help leaving them cycling between the street and hospital This paper shows however


that through a collaboration between a large inner city hospital a homelessness GP service and atargeted Housing First programme these ldquoun-help-ablerdquo individuals can be durably housed withimproved health and lower hospital healthcare costs This collaborative work also serves as amodel for the wider use of programmes addressing social determinants of health in health systems

References

500 Lives 500 Homes (2016) Housing First A roadmap to Ending Homelessness in Brisbane Brisbane

Aldridge RW Story A Hwang SW Nordentoft M Luchenski SA Hartwell G Tweed EJ Lewer DKatikireddi SV and Hayward AC (2018) ldquoMorbidity and mortality in homeless individuals prisonerssex workers and individuals with substance use disorders in high-income countries a systematic review andmeta-analysisrdquo The Lancet Vol 391 No 10117 pp 241-50

Busch-Geertsema V (2013) ldquoHousing First Europe final reportrdquo European Union Programme forEmployment and Social Solidarity Bremen and Brussels

Conroy E Bower M Flatau P Zaretzky K Eardley T and Burns L (2014) ldquoThe MISHA project fromhomelessness to sustained housing 2010-2013rdquo Mission Australia available at wwwmissionaustraliacomauwhat-we-doresearch-evaluationmisha

Davies A and Wood LJ (2018) ldquoHomeless health care meeting the challenges of providing primary carerdquoThe Medical Journal of Australia Vol 209 No 5 pp 230-4

Debra S Tara C and Laurie S (2013) ldquoA pilot study of the impact of Housing First-supported housing forintensive users of medical hospitalization and sobering servicesrdquo American Journal of Public Health Vol 103No 2 pp 316-21

DeSilva MB Manworren J and Targonski P (2011) ldquoImpact of a Housing First program on healthutilization outcomes among chronically homeless personsrdquo Journal of Primary Care amp Community HealthVol 2 No 1 pp 16-20

Fitzpatrick-Lewis D Ganann R Krishnaratne S Ciliska D Kouyoumdjian F and Hwang SW (2011)ldquoEffectiveness of interventions to improve the health and housing status of homeless people a rapidsystematic reviewrdquo BMC Public Health Vol 11 No 1 p 638

Flatau P Tyson K Callis Z Seivwright A Box E Rouhani L Ng S-W Lester N and Firth D (2018)The State of Homelessness in Australiarsquos Cities Centre for Social Impact Perth Western Australia

Gazey A Vallesi S Cumming C andWood L (2018) Royal Perth Hospital Homeless Team A Report on theFirst 18 Months of Operation University of Western Australia School of Population and Global Health Perth

Hewett N Buchman P Musariri J Sargeant C Johnson P Abeysekera K Grant L Oliver EAEleftheriades C McCormick B Halligan A Marlin N Kerry S and Foster GR (2016) ldquoRandomisedcontrolled trial of GP-led in-hospital management of homeless people (lsquoPathwayrsquo)rdquo Clinical Medicine(London) Vol 16 No 3 pp 223-9

Hwang SW Lebow JM Bierer MF Orsquoconnell JJ Orav EJ and Brennan TA (1998) ldquoRisk factors fordeath in homeless adults in Bostonrdquo Archives of Internal Medicine Vol 158 No 13 pp 1454-60

IHPA (2018) National Hospital Cost Data Collection Public Hospitals Cost Report Round 20 (Financial year2015ndash16) Independent Hospital Pricing Authority Sydney

Johnson G Parkinson S and Parsell C (2010) Policy Shift or Program Drift Implementing Housing First inAustralia Australian Housing and Urban Research Institute Melbourne

Kushel MB Perry S Clark R Moss AR and Bangsberg D (2002) ldquoEmergency department use amongthe homeless and marginally housed results from a community-based studyrdquo American Journal of PublicHealth Vol 92 No 5 pp 778-84 available at s3h

Lancione M Stefanizzi A and Gaboardi M (2018) ldquoPassive adaptation or active engagementThe challenges of Housing First internationally and in the Italian caserdquo Housing Studies Vol 33 No 1pp 40-57

Larimer ME Malone DK Garner MD Atkins DC Burlingham B Lonczak HS Tanzer K Ginzler JClifasefi SL Hobson WG and Marlatt GA (2009) ldquoHealth care and public service use and costs before andafter provision of housing for chronically homeless persons with severe alcohol problemsrdquo JAMA Vol 301 No 13pp 1349-57


Luchenski S Maguire N Aldridge RW Hayward A Story A Perri P Withers J Clint S Fitzpatrick Sand Hewett N (2018) ldquoWhat works in inclusion health overview of effective interventions for marginalised andexcluded populationsrdquo The Lancet Vol 391 No 10117 pp 266-80

Mackelprang JL Collins SE and Clifasefi SL (2014) ldquoHousing first is associated with reduced use ofemergency medical servicesrdquo Prehospital Emergency Care Vol 18 No 4 pp 476-82

Marmot M (2015) The Health Gap The Challenge of An Unequal World Bloomsbury London

Moore G Gerdtz M Manias E Hepworth G and Dent A (2007) ldquoSocio-demographic and clinicalcharacteristics of re-presentation to an Australian inner-city emergency department implications for servicedeliveryrdquo BMC Public Health Vol 7 No 1 p 320

OrgCode (2015) ldquoVulnerability index service Prioritization Decision Assistance tool in Appendix A about theVI-SPDATrdquo available at httpsd3n8a8pro7vhmxcloudfrontnetorgcodepages315attachmentsoriginal1479851654VI-SPDAT-v201-Single-CA-Fillablepdf1479851654 (accessed August 8 2018)

Pathway UK (2018) ldquoTeams pathway works with hospitals across the country helping them to develophomeless health teamsrdquo available at wwwpathwayorgukteams (accessed August 8 2018)

Perry J and Craig TKJ (2015) ldquoHomelessness and mental healthrdquo Trends in Urology amp Menrsquos HealthVol 6 No 2 pp 19-21

Reynolds F Holst H and Walsh K (2018) ldquoAustralian Alliance to End Homelessness profilerdquo 23 April

Rieke K Smolsky A Bock E Erkes LP Porterfield E and Watanabe-Galloway S (2015) ldquoMental andnonmental health hospital admissions among chronically homeless adults before and after supportive housingplacementrdquo Social Work in Public Health Vol 30 No 6 pp 496-503

Russolillo A Patterson M McCandless L Moniruzzaman A and Somers J (2014) ldquoEmergencydepartment utilisation among formerly homeless adults with mental disorders after one year of housing firstinterventions a randomised controlled trialrdquo International Journal of Housing Policy Vol 14 No 1 pp 79-97

Stafford A and Wood L (2017) ldquoTackling health disparities for people who are homeless Start with socialdeterminantsrdquo International Journal of Environmental Research and Public Health Vol 14 No 12 p 1535

Tsemberis S and Eisenberg RF (2000) ldquoPathways to housing supported housing for street-dwellinghomeless individuals with psychiatric disabilitiesrdquo Psychiatric Services Vol 51 No 4 pp 487-93

US Department of Housing and Urban Development (2014) ldquoMaking PIT counts work for your communityrdquoIntegrating the Registry Week Methodology into your Point-in-Time Count available at httpvahousingallianceorgwp-contentuploads201601Registry-Week-PIT-Integration-Toolkit_FINALpdf (accessed August 9 2018)

Vallesi S Wood N Wood L Cumming C Gazey A and Flatau P (2018) 50 Lives 50 Homes A HousingFirst Response to Ending Homelessness in Perth Second Evaluation Report Centre for Social ImpactUniversity of Western Australia Perth

Wise C and Phillips K (2013) ldquoHearing the silent voices narratives of health care and homelessnessrdquoIssues in Mental Health Nursing Vol 34 No 5 pp 359-67

Wood L Flatau P Zaretzky K Foster S Vallesi S and Miscenko D (2016) ldquoWhat are the health andsocial benefits of providing housing and support to formerly homeless peoplerdquo AHURI Final Report No 265Australian Housing and Urban Research Institute Melbourne

Wood L Vallesi S Kragt D Flatau P Wood N Gazey A and Lester L (2017) ldquo50 Lives 50 homes ahousing first response to ending homelessness First evaluation reportrdquo Centre for Social Impact University ofWestern Australia Perth

Woodhall-Melnik JR and Dunn JR (2016) ldquoA systematic review of outcomes associated with participationin Housing First programsrdquo Housing Studies Vol 31 No 3 pp 287-304

Author Affiliations

Lisa Wood is Associate Professor at the School of Population and Global Health University ofWestern Australia (UWA) Crawley Australia and Research Fellow at the UWA Centre for SocialImpact Crawley Australia

Nicholas JR Wood and Shannen Vallesi are both based at the Centre for Social Impact UWABusiness School University of Western Australia Crawley Australia and School of Populationand Global Health University of Western Australia Crawley Australia


Amanda Stafford is based at Royal Perth Hospital Perth Australia

Andrew Davies is based at Homeless Healthcare West Leederville Australia

Craig Cumming is Research Fellow at the School of Population and Global Health University ofWestern Australia Crawley Australia

About the authors

Dr Lisa Wood has nearly three decades of experience in public health and health promotion inWA nationally and internationally Dr Woodrsquos research is focussed on the need for moreupstream and join-up solutions to address complex social challenges such as homelessnessincarceration social isolation and closing the gap in Aboriginal wellbeing Her researchhas had considerable traction with policy makers and government and non-governmentagencies and she is highly regarded for her collaborative efforts with stakeholders to ensureresearch relevance and uptake Dr Lisa Wood is the corresponding author and can becontacted at lisawooduwaeduau

Nicholas JR Wood is Research Assistant at the School of Population and Global Health at theUniversity of Western Australia and has been since 2016 He has worked on and assisted withseveral homelessness evaluations in this time as well as two evaluations of programmesdeveloped for at-risk and vulnerable young people

Shannen Vallesi is Research Officer at both the School of Population and Global Health and theCentre for Social Impact at the University of Western Australia and has been working onnumerous homelessness evaluations since 2015 Her research focus is on the complex andintertwined nature of homelessness poor physical and mental health outcomes social exclusionand the impact of intervention on these

Dr Amanda Stafford is an Emergency Consultant by training and the Clinical Lead of the RoyalPerth Hospital Homeless Team which has been operating since mid-2016 She is also an activeadvocate at policy level aiming to change the way our government and community seeshomelessness by using data to show that itrsquos more expensive to leave people homeless than paythe cost of housing and supporting them She works closely with the School of Population andGlobal Health at the University of Western Australia to produce data to underpin this effectivestrategy for social change

Dr Andrew Davies established Homeless Healthcare in 2008 It is now Australiarsquos largestdedicated general practice for people experiencing homelessness having over 12 communitybased clinics and a street outreach team He has led a number of innovations in homelesshealthcare including the establishment of the first GP in-reach hospital service for homelesspeople in the Southern Hemisphere

Craig Cumming is an early career Researcher focusing on the health social and justice outcomesof socially disadvantaged people with a particular focus on drug and alcohol misuse and socialdisadvantage for people in contact with the justice system as well as people experiencinghomelessness He is currently completing a PhD Degree at the Centre for Health ServicesResearch at the School of Population and Global Health at the University of Western Australia



Homeless medical respite serviceprovision in the UK

Samantha Dorney-Smith Emma Thomson Nigel Hewett Stan Burridge and Zana Khan

Abstract

Purpose ndash The purpose of this paper is to review the history and current state of provision of homelessmedical respite services in the UK drawing first on the international context The paper then articulates theneed for medical respite services in the UK and profiles some success stories The paper then outlines theconsiderable challenges that currently exist in the UK considers why some other services have failed andproffers some solutionsDesignmethodologyapproach ndash The paper is primarily a literature review but also offers original analysisof data and interviews and presents new ideas from the authors All authors have considerable experience ofassessing the need for and delivering homeless medical respite servicesFindings ndash The paper builds on previous published information regarding need and articulates the humanrights argument for commissioning care The paper also discusses the current complex commissioningarena and suggests solutionsResearch limitationsimplications ndash The literature reviewwas not a systematic review but was conductedby authors with considerable experience in the field Patient data quoted are on two limited cohorts ofpatients but broadly relevant Interviews with stakeholders regarding medical respite challenges have beenfairly extensive but may not be comprehensivePractical implications ndash This paper will support those who are thinking of undertaking a needs assessmentfor medical respite or commissioning a new medical respite service to understand the key issues involvedSocial implications ndash This paper challenges the existing status quo regarding the need for a ldquocost-savingrdquorationale to set up these servicesOriginalityvalue ndash This paper aims to be the definitive paper for anyone wishing to get an overview of this topic

Keywords Homeless Needs assessment Medical respite care Commissioning of care Inclusion healthIntermediate care


Introduction

Pathway is a charity that works to improve access to quality healthcare care for peopleexperiencing homelessness A core function of Pathway is to provide individual careco-ordination for homeless patients through a multi-disciplinary team (MDT) approachPathway teams work with patients during their admission to support them into housing supportand social care (Dorney-Smith Hewett and Burridge 2016 Dorney-Smith Hewett Khan andSmith 2016) However despite this expert support not all discharges are timely or to idealdestinations and one reason for this can be a lack of adequate step-down facilities

Medical respite is an American term for clinically supported intermediate care for homelesspeople in the community ndash both step down from hospital and step up from the community(National Health Care for the Homeless Council 2016) This includes peripatetic nursing andbed-based solutions ranging from low-level supported housing to comprehensive clinical careSuch services provide a safe recovery-based environment to discharge homeless patients toand also sometimes as a step-up environment to avoid an acute hospital episode There is agrowing international evidence base which shows that such services result in positive outcomesfor patients (Doran et al 2013 Hwang and Burns 2014)

Samantha Dorney-Smith isNursing FellowEmma Thomson is ProjectManager Nigel Hewett isMedical Director andStan Burridge is EbE ProjectLead all at PathwayLondon UKZana Khan is GP Clinical Leadat the Lambeth Hospital ndash KHPPathway Homeless TeamLondon UK


The UK is slowly beginning to see provision appearing in major urban areas with large streethomeless populations The Department of Healthrsquos (DH) Homeless Hospital DischargeFund (HHDF) resulted in the creation of several new pilot medical respite type projects(Homeless Link 2015) However medical respite schemes in the UK have met with mixedsuccess overall Some have survived and continue to provide intermediate care to homelesspatients Others have fallen by the wayside despite achieving some notable positive outcomesfor services users

This paper examines the current evidence base for medical respite care reviews current provisionin the UK outlines the challenges these services face and provides guidance for those wishing toset up medical respite services in the UK

Why is medical respite care needed

Chronic homelessness is a marker of complexity and multiple exclusion with roots in earlychildhood (Roos et al 2013) Neglect and abuse often lead to personality issues and mentalillness and attempts to self-medicate with alcohol and drugs lead to dependency A deteriorationin physical health follows and the combination of physical ill health combined with mental ill healthand drug or alcohol misuse (tri-morbidity) is often central to the challenge of managing homelesspatients in an acute hospital setting (Hewett et al 2012) In many cases a hospital admissionmay only touch the surface of a patientrsquos underlying issues and a revolving door scenario is likely

As a result the annual cost of unscheduled care for homeless patients is eight times that of thehoused population (Department of Health 2010) and homeless patients are ovserrepresentedamongst frequent attenders in AampE Yet despite this expenditure patients have a reduced qualityof life caused by multi-morbidity (Barnett et al 2012) and also experience higher rates ofpremature death (Crisis 2011 Aldridge et al 2017) As such the perceived need for medicalrespite care on discharge can be for many reasons ndash as an immediate solution to housingproblems (because the patient is not ldquostreet fitrdquo) or to continue necessary medical treatment orto start work towards full recovery ndash but in many cases it will be needed for all three

Specifically clients may need assistance to engage with primary care and outpatient careBarriers to primary care for homeless patients in the UK are well documented (Homeless Link2014 Project London 2014) and in terms of outpatient care it is estimated that only 3 per centof homeless people with Hepatitis C receive treatment (Story 2013) Reasons for this includeoutpatient appointments not being received patients having to travel too far for appointmentsassumptions being made that a person will not attend and a patient needing support to attendan appointment due to mental health or addictions problems or cognitiveothercommunication difficulties

Literature review

Methodology

A literature review was undertaken to support this paper A search using the terms ldquohomelessintermediate carerdquo and ldquomedical respiterdquo was undertaken on Medline and CINAHL viaOpenAthens All relevant articles were reviewed and the articles that were then chosen forinclusion in this paper were selected by the authors on the basis of their relevance andimportance This selection was made on the basis of the authorsrsquo expertise in this area

Medical respite in the literature

Many international medical respite projects have been described eg in Canada (Podymowet al 2006) Oslo (Hovind 2007) Rotterdam (van Tilburg et al 2008) Amsterdam (van Laereet al 2009) Washington and Boston (Kertesz et al 2009 Zerger et al 2009) and Italy(De Maio et al 2014)

In terms of the UK literature the need for medical respite care was first considered in the Londonborough of Lambeth where the Homeless Intermediate Care Steering group published ldquoThe road


to recovery ndash a feasibility study into homeless intermediate carerdquo (Lane 2005) The report did notfind any replicable models of intermediate care in the UK at that time A clear need was identifiedin the report but there was no consensus on the ideal model

However this thinking led to a hostel-based homeless intermediate care pilot in Lambeth(Dorney-Smith 2011) which showed a 77 per cent reduction in admissions and 52 per centreduction in AampE attendances The project continues now but remains only available to thosealready resident in the two host hostels

Several publications come from the USA where homeless medical respite services are commonAn original monograph from an American homeless respite care network (Ciambrone andEdgington 2009) recommends a free-standing unit rather than a hostel-based one Principalreasons are the challenge of maintaining sobriety in a hostel and a tendency for hostel-basedservices to have to take clients with lower levels of health and social care need However it isnoted that a free-standing unit is inherently more expensive as it does not allow for the sharing ofstaffing costs

Reflections on what happens without medical respite are also helpful One study (Biedermanet al 2014) highlights that in the absence of a designated medical respite programme aldquopatchwork medical respiterdquo approach emerges as staff find local work-arounds which is verytime consuming and of variable quality and benefit This results in considerable frustration forservice providers and users with many instances of prolonged hospital stays

Similar thinking has emerged in the UK in a reflection on the ldquoLiverpool Protocolrdquo (Whiteford andSimpson 2015) This is a policy held by the hospital discharge team that maintains multi-agencyrelationships and is supported by ring-fenced hostel beds provided by the Local Authority (LA)The study highlights the lack of intermediate care and palliative care beds which diminishes thedischarge opportunities for homeless patients

In 2016 the National Health Care for the Homeless Council in the USA published ldquoStandards formedical respite programmesrdquo (NHCHC 2016) These guidelines focus on the need for goodquality accommodation 24-h staffing acute and preventative healthcare delivery as well as astrong focus on safetyrisk management ongoing quality improvement (as seen from a patientrsquosperspective) and effective move on

A realist synthesis of the literature on intermediate care for homeless people (Cornes et al 2017)notes the importance of collaborative care planning service user involvement and integratedworking The paper asks questions about whether respite services are just that or whether theyare needed to substitute for the loss of other supported housing services

Finally Pathway (2012 2013) has so far published four papers on the topic of medical respitestarting with an initial feasibility study and service user responses (Burridge 2012) Morerecently a third paper describes a needs assessment undertaken for the South London areaoutlining a detailed analysis of local need (including the methodology) and potential options forservice delivery (Dorney-Smith and Hewett 2016) This paper reviews a number of medicalrespite projects then operating in the UK ndash several started at the time of the HHDF This paperwas later summarised in a journal article (Dorney-Smith Hewett and Burridge 2016 Dorney-Smith Hewett Khan and Smith 2016) and outlines a number of distinct groups of clients thatneed medical respite provision and how this complicates decisions regarding service provision

Recently Pathway has published a paper outlining the learning from their ldquoPathway to Home(P2H)rdquo project with University College Hospital London (UCLH) at a local hostel which is stillrunning (Thomson 2017) Key learning points include the need to allow a project plenty of time toembed and adapt a requirement to meet a variety of different client profiles the need for excellentservice partnerships and the argument for pan London commissioning and provision of suchservices Publishing of a fifth Pathway paper ndash A needs assessment for medical respite in theNorth Central London area ndash is awaited

Based on all their learning in this area Pathway published standards for medical respite withintheir Homeless and Inclusion Health Care Standards review (Faculty for Homeless and InclusionHealth 2018) (see Box 1)


Box 1 Standards for medical respite

Standards for medical respite ndash taken from Faculty for Homeless and Inclusion Health(2018) Homeless and Inclusion Health Standards for Commissioners and Service Providers

A detailed analysis of local need should be undertaken to define the nature of the service required

Projects with a high level of integrated planning with the Local Authority are recommended Bedsshould ideally not be in local authority control to maintain flow Any model requiring housingassessed local connection is unlikely to maximise the potential for usage of beds

Projects should aim to provide holistic person-centred case management covering physical healthmental health and drug or alcohol misuse needs as required

Projects should ideally have on-site access to a range of primary care services Close links tohomeless GP practices will be beneficial

Projects should ideally be dry or aim to minimise alcohol and drug misuse behaviour on site

Projects should ideally be able to provide for patients with physical disabilities and substituteprescribing needs

Projects should be able to actively provide or promote access to meaningful activity eg educationtraining sports and arts activities

Full consideration of potential move on options eg clients with complex needs or no recourse topublic funds should be given when designing medical respite service

Pilot projects should be given adequate time to embed before being evaluated (two to three yearsminimum) as they may not have time to prove their worth without this

In addition projects should ideally be psychologically informed environments with regularreflective practice

Cost benefit of medical respite projects

Most studies have concentrated on the potential cost savings resulting from reduced use ofsecondary care while highlighting the benefit to patients

Research in Chicago has shown that intermediate care for homeless people leaving hospitalreduces future hospitalisations by 49 per cent (Buchanan et al 2006)

A systematic review of American research into intermediate care for homeless people (Doranet al 2013) showed that medical respite programmes reduce future hospital admissionsin-patient days and hospital readmissions They also result in improved housing outcomesResults for emergency department use and costs were mixed but promising

A recent Lancet evidence review also confirmed these benefits of medical respite (Hwang andBurns 2014) Medical respite programmes that provide homeless patients with a suitableenvironment for recuperation and follow-up care on leaving the hospital reduce the risk ofreadmission and the number of days spent in hospital

Analysis from the Bradford Pathway teamrsquos collaboration with Horton Housing to run amedical respite unit identified significant annual secondary healthcare cost savings (Lowson andHex 2014)

The most recent national analysis was an evaluation of the HHDF carried out by Homeless Link(2015) with DH funding Access to dedicated accommodation alongside link workers improvedhousing outcomes with 93 per cent of clients discharged to appropriate accommodationcompared to 71 per cent overall They recommended a model where accommodation iseither directly linked to the project (via bespoke units or ring-fenced beds in existing projects)or links are established with a local housing provider or rent deposit scheme so suitableaccommodation can be easily accessed


What do we know about need

Several articles document need in higher support type homeless medical respite populationsUnsurprisingly these populations have been noted to have a high prevalence of addictionsmental health issues liver disease HIV Hepatitis C past or current TB chronic leg ulcers poorlymanaged chronic disease epilepsy or fits and cancer Sepsis and physical trauma-relatedconditions are also common (van Laere et al 2009 Dorney-Smith 2011 de Maio et al 2014Imogen Blood 2016 Thomson and Dorney-Smith 2018)

These populations also show high levels of unscheduled service usage For example in a detailedanalysis of a potential medical respite cohort in South London (Dorney-Smith Hewett andBurridge 2016 Dorney-Smith Hewett Khan and Smith 2016) 56 patients accrued 472 AampEattendances 181 admissions and 2561 bed days during the study year A similar recent similarexercise at UCLH (Thomson and Dorney-Smith 2018) revealed a similar pattern with 1119 AampEattendances and 247 admissions for 69 patients during the study year

Analysis of both the above cohorts (see Table I) additionally revealed a population with significantmobility problems a need for substitute prescribing and nearly a quarter of clients with no recourseto public funds (NRPF) (although it is important to note that these are London populations) Mostpatients in the two cohorts had immediate housing issues (ie they were not able to return to a priorhousing situation) a small number of clients had care needs and in the second cohort 188 per centwere noted to have end-of-life care issues (not assessed in the original study)

For the North Central London cohort further analysis (Thomson and Dorney-Smith 2018)identified 71 per cent of patients as having a behavioural issue Behavioural issues includedviolence aggression chronic non-compliance active self-neglectputting self at risk or chaoticaddiction leading to for example overdoses fits or attention seeking behaviour Additionally217 per cent patients had a communication issue This was related to mental capacity limitedEnglish skills and difficulties with literacy or sensory issues such as poor hearing or sight Thisobviously has implications for service provision

Patient categories

Within both of these needs assessments distinct groups of clients with medical respite needshave emerged Patients audited have broadly fallen into four categories with somewhat differingneeds (see Table II)

Length of stay in respite

It is notable that respite care is generally a longer-term intervention Average lengths of staydescribed include 40 days (Podymow et al 2006) 6ndash12 weeks (Dorney-Smith 2011) 20 days(van Laere et al 2009) and 20 weeks (Imogen Blood 2016) although in the case of the Italianproject only 41 per cent stayed longer than a week (de Maio et al 2014)

Table I Health and support needs for medical respite populations

HealthSupport needs 76 clients ndash South London () 69 clients ndash North Central London ()

Physical health need 816 913Addiction 605 609Mental health 763 638Mobility issues (at point of discharge includes clients with shortness of breath) 329 449Intravenous drug use potentially requiring substitution therapy 250 246Nursing input needed more than once a week 329 435Housing issue 763 928No local connection 329 551Confirmed no recourse to public funds 224 246Care needs 8 130End-of-life care issues 188


Importantly the under-provision of care homes for this client group may create an apparent needfor medical respite for those requiring ongoing care provision but lacking a placementparticularly if they are under 65 Assessment of the number of care beds in an area and theadequacy of this provision is an important part of assessing need

Is there a business argument for providing medical respite

Clearly populations requiring homeless medical respite present with high levels of unscheduled andemergency health service usage however cost savings should not be the main driver for changeThe main argument for funding services is a human rights one similar to the provision of cancer orpalliative care Although services need to be monitored well and prove themselves to be efficientand effective it is not acceptable to argue that such services should only be commissioned on acost-saving basis This is tantamount to saying that the NHS is only prepared to provide necessarycare to homeless people if it saves the NHS money ndash which is clearly not equitable

It is however perfectly reasonable to work towards for example a reduction in AampE attendanceas a measure of effectiveness (assuming trends in the local population are taken note of eg anincrease in rough sleeping numbers) just so long as this is not the only marker Quality indicatorseg engagement in follow-up services patient satisfaction measures should have equal weight

It is important to note that patients often have multiple complex health needs and may need tocome back into acute in-patient services irrespective of the quality of care they are given in amedical respite setting However the logical extension of the cost-saving argument leads to aconclusion that the cheapest solution is to not intervene and let clients die early which is clearlyunethical and not a desired outcome

Recovery if successful will most likely result in significant cost savings to the wider economy(eg in criminal justice a reduction in cost of evictions etc) but this will be difficult to measurewithout a joined-up focus and long-term outcome measurement As such measuringincremental steps towards stability should also be part of outcome measurement egattendance at appointments engagement with treatment and housing stability

What do patients say

Four UK studies (Lane 2005 Hendry 2009 Burridge 2012 Dorney-Smith and Hewett 2016)have asked potential service users for their perceptions of the type of service required

In summary service users

Still describe negative experiences during all phases of the hospital experience includingdischarge

Think homeless medical respite services are needed

Do not think existing homeless hostels are a good environment for respite

Think respite facilities should be ldquodryrdquo This is a key finding which has been consistentlyreplicated and is important because it means that services delivered within existing hostelsare unlikely to be successful

Table II Types of patients requiring medical respite

Patient category76 clients ndash South

London ()

69 clients ndash

North CentralLondon ()

Low-level or specific discrete medical needs ndash has recourse housing requires resolution not prior rough sleeper 30 174No recourse to public funds with significant medical problems eg cancer or HIVTB Needs housing and somesupport mostly past sofa surfers 11 145Care needs resulting from medical problem plus chronic addiction or end stage cancer mixed background 8 130Chaotic tri-morbid clients ndash generally a chronic history of rough sleeping 51 551


Are split on whether controlled drinking for some could be applied successfully ndash but morethink this is not ideal

Are able to see the benefits of a variety of forms of respite provision but feel that high supportdry stand-alone unit with a recovery focus is most needed

Think specialist housingbenefitsemployment support should be provided

Think mental health support should be provided

Think end-of-life care could be provided in a respite setting

Are spilt on whether step-downmental health and physical healthcare clients can bemanagedtogether (particularly in the cases of very unwell mental health clients)

Think medical respite should be available for all not just those with local connection Howeverit is recognised that non-local people might have time-limited intervention and may end upbeing discharged to the streets (as they would from hospital)

Some current projects in the UK and their funding streams

This section outlines service details and funding streams for five currently funded projects

Health Intensive Case Management Health Inclusion Team Lambeth

This project is a nurse-led intensive case management project evolved from a pilot project(Dorney-Smith 2011) that has been running continuously since 2009 It supports the existinghigh need population residing in two LA commissioned supported accommodation homelesshostels There is a caseload of eight and the Clinical Commissioning Group (CCG) funds thein-reach nurse and GP support for the project Local addictions service staff do in-reach andthere is on-site MethadoneSubutex prescribing Some rooms are fully accessible Psychologyinput is available for 11 work and staff support although the level of support has recently beenreduced due to a lack of continuation funding despite a successful Guys and St Thomasrsquohospital charity funded pilot The project takes both step-up and step-down clients The projectcannot take anyone not already residing within these two hostels and move on from the caseloadhas been an issue Addictions recovery support is also difficult in the hostel environments

Pathway to Home University College Hospital Camden

This two-to-four-bedded step-down service has been operational since 2015 (Thomson 2017)Originally funded as a pilot under the HHDF the service is now funded by UCLH hospital P2H ispart of UCLHrsquos wider HospitalHome service where patients can be sent home (or in this caseto a local independent voluntary sector hostel called Olallo House) to complete the last few daysof their treatment Individuals transferred to this service are still managed as hospital inpatientsThe service is open to the majority of clinical specialities with consultants making the decision onsuitability for transfer with the Pathway team Nurses visit patients daily The hospital funds on aspot purchase basis and the target length of stay for P2H is five days although there have beencases of clients with NRPF with cancer or TB infection being funded for longer The five-day targetgives limited scope for any recovery-based interventions and the hostel is not accessible forwheelchairs However the service does provide methadone and is situated close to the hospitalmaking it possible for the Pathway team to continue with case management Due to the hospitalfunding of the beds and the hostel being outside LA control the project can take patients who donot have current or local housing eligibility

Westminster Integrated Care Network for Homeless Health Westminster

This peripatetic support service is managed in partnership by the specialist homeless healthservices in Westminster Since 2016 the service has supported clients by placing them in LAmanaged physical or mental health hostel beds spot purchased from the LA by the CCGAlternatively clients can be supported through funding for a BampB placement for up to six weeks


Originally a ten-bedded service the number of beds has reduced to four beds despite being wellutilised The reduction seems to relate to a perception that funding has not led to any specificallyhealth-related cost benefits and has been used primarily to enable other types of casework egfor clients with NRPF The service has also been reconfigured to focus on step-up care to preventadmissions as this is perceived to confer more financial benefits for the CCG The service workswith clients with a Westminster connection and cases are managed via a weekly MDT that bringsall treatment partners together A key benefit of this service is fully integrated physicalmentalhealth support

Gloria House Tower Hamlets

Launched in January 2018 Gloria House is a partnership between Peabody Housing (nowmerged with Family Mosaic) the Royal London Hospital Pathway Team and Tower HamletsCCG The housing association has renovated one of its properties to provide step-down care forhomeless patients being discharged from the Royal London Hospital The Pathway team selectssuitable patients for transfer and works alongside PeabodyFamily Mosaic colleagues to ensuredischarged patients are supported to register with a GP and other community-based healthcaresupport Tower Hamlets CCG have commissioned the beds for a pilot period Gloria House staffwork to claim housing benefit where clients are eligible During the initial 11 weeks 6 out of the 10occupants were eligible for housing benefit and Peabody managed to reclaim housing benefit onhalf of these clients Initially a service for clients with lower needs staff now feel more confidentabout accepting more ldquochallengingrdquo referrals

Bradford Respite and Intermediate Care Support Services (BRICCS) Bradford

Bevan Healthcare provides a range of fully integrated services to support homeless healthcare inBradford This includes a Pathway homeless hospital discharge team a street medicine teamand a 14-bedded medical respite project for discharged patients (BRICCS) BRICCS is deliveredin partnership with Horton Housing and local social care services and is managed via a weeklyMDT It has been running since December 2013 The health support element of the project isfunded jointly by the CCG and public health Beds are paid for by housing benefit ndash clients have tobe eligible although not actually in receipt of housing benefit when they are admitted Socialservices have also funded beds for NRPF clients with care needs

Bevan Healthcare received an Outstanding CQC rating in February 2015 and this includedan assessment of the developing outreach and respite services An independent analysisfrom the BRICCS identified annual secondary care cost savings of pound280000 and high levelsof client satisfaction with services (Lowson and Hex 2014) The project has won both ahousing and a community impact award and is an example of highly successful trulyintegrated service

Homeless Accommodation Leeds Pathway (HALP) Leeds

This hostel-based service provides 3 intermediate care beds within a 15-bedded LA-fundedvoluntary sector provided supported accommodation hostel called St Georgersquos CryptThe step-down beds are funded by the CCG and can be therefore be used for those withclients NRPF Intensive support for the three beds is provided by HALP homeless hospitaldischarge team

This hostel previously used to receive people from hospital without HALP team support but thehostel manager feels that much better health outcomes are achieved with this service anddeaths on the streets in Leeds have been much reduced

Outcomes and lessons learned

All projects reviewed for this paper have demonstrated reduced emergency care usage andimproved health outcomes (eg Dorney-Smith 2011 Lowson and Hex 2014 Imogen Blood2016 Dorney-Smith and Hewett 2016 Thomson 2017)


However when some projects have failed to deliver maximum bed occupancy or a clear costsaving they have often been decommissioned ndash rather than a clear value being placed on thequality care that has been provided and work being put in to enable these services to understandthe challenges and meet the continuing needs For example all four St Mungos HospitalDischarge Network services that commenced under the HHDF have since disappearedBreathing Space a Southampton project also ceased functioning after pilot money from theHHDF ran out More recently the number of beds provided in the Westminster Integrated CareNetwork has been reduced from 10 to 4 All these services have been well evaluated by patientsand this is a considerable loss to the sector

Interviews with service providers and analysis of project reports reveal multiple challenges thathave either stopped projects meeting the needs of some clients or has led to decommissioningfor other reasons (Dorney-Smith and Hewett 2016 Thomson and Dorney-Smith 2018)

Core challenges have been

rejected referrals for clients with NRPF andor no local connection as admission to the bedshas been controlled by the LA

a lack of alcoholsubstance misuse-free respite beds in the projects as they have beenprovided in hostels

a need for disability accessible accommodation andor personal bathroom facilities (often notavailable in hostels or not in the amounts required)

a need for ldquoon the spotrdquo substitute prescribing arrangements (to continue arrangements inhospital) which in some cases has not been available

bed blocking due to clients with high support needs

a KPIcommissioning focus generally based entirely on targets set for bed occupancy andreducing emergency and unscheduled healthcare usage and

short-term funding which does not allow projects to learn adapt or embed to meet the needsof as many referrals as possible

For example one six-bedded London service projects in a homeless hostel environmentunderwent a formal evaluation (Imogen Blood 2016) Provision of care was found to be verygood but the evaluation showed that of the 53 referrals received in the previous 18 months 29were not taken on Most of the rejections were for reasons other than bed availability includinghaving NRPF (7) having too high needs (4) no local connection (2) no accessible bed (1) neededldquodryrdquo bed (2) picked up by another service (2) client abandoned or hospital discharged beforereferral process complete (7) or no bed available (1) This demonstrates the challenges but alsothe evident need

An example of a project that has adapted to meet a need is the P2H project P2H incorporated amethadone protocol to meet substitution therapy needs This began six months after the start ofthe project following several rejected referrals due to a need for substitute prescribing A safe andeffective solution to the off-site dispensing of a controlled drug to patients still classed as hospitalinpatients had to be found The new methadone policy has been a success and has opened upthe service to a wider cohort of patients

Discussion ndash future funding models

While the need for medical respite care seems undisputed one of the main barriers to all provisionhas been the siloed and depleted budgets that exist across the voluntary sector housing andsocial care and workable solutions need to be found

Locally Agreed Tariff (LAT)

A LAT is an idea that has been suggested by Pathway as a possible solution A LAT is an agreedrate that an accredited provider could charge health (in this case local CCGs) for providing


medical respite services as an alternative to hospital admission The tariff could have differentday rate charges depending on the dependency of the patient at discharge and could decreaseover time

To be successful a tariff would need to be sufficient to cover the costs ofaccommodation rental and house-keeping specialist primary care outreach and casemanagement but less than the cost of repeated acute admissions Services would most likelybe provided in partnership by a community housing provider and a specialist primarycare provider Eligibility criteria tapering mechanisms and rapid access protocols would needto be pre-agreed

A LAT would prompt the local market to provide the care and might encourage diversity ofprovision perhaps with the prospect of ldquodryrdquo units for those who wish to continue their detoxThis could happen because each locality would not need to have enough potential usersin its own borough to justify provision Provision can also be placed anywhere andovercomes the local connection block because this would be short-term healthcare provisionnot housing provision It could also make use of established buildings that have beenotherwise decommissioned However any prospective service would still need ldquopump-primerdquofunds to prepare a building recruit and employ staff and provide a cash flow until the tarifffunding came through

Applying a Locally Agreed Tariff to a hostel-based medical respite service some keyprinciples

The NHS tariff is a set of prices and rules used by commissioners and providers of NHS careWithin an agreed tariff the expectations of care quality and health outcomes and the priceto be paid for this are set out and guaranteed in advance

Service to be provided

hostel style beds provided for self-caring patients fit for medical discharge and

in-reach medical support (eg visiting nurses physiotherapy OT and substance misuse support) setup in advance by the referring hospital from existing local resources

Payment principles

agreed tariff for step-down care would be claimed by a hospital following discharge of a patient froman acute admission to a medical respite hostel bed

funding claimed by the hospital would then be paid to the medical respite provider

daily costs in the unit will be equal to or less than the average daily tariff of a post trim point acuteadmission

funding would be weighted to support an average duration of stay of 5ndash14 days and then taperedfor a maximum duration of stay of 4ndash6 weeks and

maximum total cost equivalent to the average cost of another acute admission

Housing benefit

Another option for funding the bed costs associated with medical respite is the reclamation ofhousing benefit model currently being piloted at Gloria House and already being utilised byBRICCS With around 60ndash70 per cent of patients being eligible for housing benefit even inLondon this may represent a real opportunity for projects providing a recovery focus andexpecting to have at least some clients staying for longer periods Eligibility for housing benefitis not related to local connection and this gets around the eligibility problem whereservices have previously been provided in LA run supported accommodation hostels Againa potential provider would most likely need ldquopump-primerdquo money to enable clear processes tobe established


Joint commissioning

Joined-up commissioning with financial input from a partnership of potentially health publichealth housing social care and criminal justice to support much longer pilots should beconsidered with all partners together reviewing the effectiveness of the interventions

The ldquoLondonrdquo challenge

It should be noted that projects have often had more success outside London where localhomeless patients are more likely to have a local connection and less likely to have NRPFTo avoid this local connection and NRPF conundrum London would benefit from aLondon-wide medical respite solution Whilst many London projects are demonstratingsuccessful ldquoinnovation at the marginsrdquo it is not at anything like the scale required to delivermeaningful economies of scale or deal with the level of demand across the capital Ideally NHSEngland (London Region) the London CCGs and the Greater London Authority need to adopta partnership approach and address the challenge of working across boundaries in a waywhich local projects are unable to do

Summary

This paper has outlined a need for medical respite in the UK and profiled some successfulservices However the paper has also outlined the considerable challenges that currently existand has proffered some solutions to fund more recovery-based services over a longer timeframe

These challenges emphasise that a short-term cost savings argument for providing services isunlikely to be successful on its own but the obvious need demonstrated within this paper meansthat routes to provision still need to be found Funding these services is a human rights issue andshould not be optional

For anyone considering undertaking a needs assessment for a medical respite service in theirarea please now see Pathwayrsquos guidance ldquoHow to undertake a medical respite needsassessmentrdquo ndash downloadable from the Pathway website (wwwpathwayorguk)

References

Aldridge R Story A Hwang S Nordentoft M Luchenski S Hartwell G Tweed E Lewer DVittal Katikireddi S and Hayward A (2017) ldquoMorbidity and mortality in homeless individuals prisoners sexworkers and individuals with substance misuse disorders in high-income countries a systematic review andmeta-analysisrdquo Lancet Vol 391 No 10117 pp 241-50

Barnett K Mercer SW Norbury M Watt G Wyke S and Guthrie B (2012) ldquoEpidemiology ofmultimorbidity and implications for health care research and medical education a cross-sectional studyrdquoLancet Vol 380 No 9836 pp 37-43 doi 101016S0140-6736(12)60240-2

Biederman DJ Gamble J Manson M and Taylor D (2014) ldquoAssessing the need for a medical respiteperceptions of service providers and homeless personsrdquo Journal of Community Health Nursing Vol 31No 3 pp 145-56

Buchanan D Doblin B Sai T and Garcia P (2006) ldquoThe effects of respite care for homeless patients acohort studyrdquo American Journal of Public Health Vol 96 No 7 pp 1278-81

Burridge S (2012) ldquoLondon Pathway Medical Respite Centre Feasibility Study ndash Advisory Panel ResponserdquoPathway London

Ciambrone S and Edgington S (2009) ldquoMedical respite services for homeless people practical planningrdquoHealth Care for the Homeless Respite Care Providers Network June available at wwwnhchcorgwp-contentuploads201109FINALRespiteMonograph1pdf (accessed 9 December 2018)

Cornes M Whiteford M Manthorpe J Neale J Byng R Hewett N Clark M Kilmister A Fuller JAldridge A and Tinelli M (2017) ldquoImproving hospital discharge arrangements for people who are homelessa realist synthesis of the intermediate care literaturerdquo Health and Social Care in the Community Vol 7 No 12pp 1-15


Crisis (2011) ldquoHomelessness a silent killerrdquo London December available at wwwcrisisorgukending-homelessnesshomelessness-knowledge-hubhealth-and-wellbeinghomelessness-a-silent-killer-2011(accessed 9 December 2018)

De Maio G Van den Bergh R Garelli S Maccagno B Raddi F Stefanizzi A Regazzo C andZachariah R (2014) ldquoReaching out to the forgotten providing access to medical care for the homeless inItalyrdquo International Health Vol 6 No 2 pp 93-8

Department of Health (2010) ldquoHealthcare for Single Homeless Peoplerdquo 22 March available at httpswebarchivenationalarchivesgovuk20130123201505 wwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_114250 (accessed 9 December 2018)

Doran KM Ragins KT Gross CP and Zerger S (2013) ldquoMedical respite programs forhomeless patients a systematic reviewrdquo Journal of Health Care for the Poor and Underserved Vol 24No 2 pp 499-524

Dorney-Smith S (2011) ldquoNurse led homeless intermediate care an economic evaluationrdquo British Journal ofNursing Vol 20 No 18 pp 1193-7

Dorney-Smith S and Hewett N (2016) ldquoKHP Pathway Homeless Team Scoping Paper options for deliveryof lsquohomeless medical respitersquo servicesrdquo available at wwwpathwayorgukwp-contentuploads201605Homeless-Medical-Respite-Scoping-Paperpdf (accessed 9 December 2018)

Dorney-Smith S Hewett N and Burridge S (2016) ldquoHomeless medical respite in the UKa needs assessment for South Londonrdquo British Journal of Healthcare Management Vol 22 No 8pp 215-23

Dorney-Smith S Hewett N Khan Z and Smith R (2016) ldquoIntegrating health care for homelesspeople ndash the experience of the KHP Pathway Homeless Teamrdquo British Journal of Healthcare ManagementVol 22 No 4 pp 225-34

Faculty for Homeless and Inclusion Health (2018) ldquoHomeless and Inclusion Health Standards forCommissioners and Service Providersrdquo Pathway London available at wwwpathwayorgukwp-contentuploadsInclusion-Health-Standards-for-Commissioners-and-Service-Providerspdf

Hendry C (2009) ldquoEconomic Evaluation of the Homeless Intermediate Care Pilot Projectrdquo Lambeth PCT London

Hewett N Halligan A and Boyce T (2012) ldquoA general practitioner and nurse led approach to improvinghospital care for homeless peoplerdquo British Medical Journal Vol 345 No e5999 available at wwwbmjcomcontent345bmje5999

Homeless Link (2014) ldquoThe Unhealthy State of Homelessness ndash Health Audit Resultsrdquo available at wwwhomelessorguksitesdefaultfilessite-attachmentsThe20unhealthy20state20of20homelessness20FINALpdf (accessed 9 December 2018)

Homeless Link (2015) ldquoEvaluation of the Homeless Hospital Discharge Fundrdquo January available at wwwhomelessorguksitesdefaultfilessite-attachmentsEvaluation20of20the20Homeless20Hospital20Discharge20Fund20FINALpdf (accessed 9 December 2018)

Hovind OB (2007) ldquoStreet hospital for drug addicts in Oslo Norwayrdquo FEANTSA European Network ofHomeless Health Workers (ENHW) Brussels Vol 2 pp 7-8

Hwang S and Burns T (2014) ldquoHealth interventions for people who are homelessrdquo The Lancet Vol 384No 9953 pp 1541-7

Imogen Blood (2016) ldquoIndependent evaluation of hospital discharge service and homeless healthcareprovisionrdquo NEL Commissioning Support Unit London

Kertesz SG Posner MA OrsquoConnell JJ Swain S Mullins AN Shwartz M and Ash AS (2009)ldquoPost-hospital medical respite care and hospital readmission of homeless personsrdquo Journal of Prevention andIntervention in the Community Vol 37 No 2 pp 129-42 doi 10108010852350902735734available at wwwhomelessorguksitesdefaultfilessite-attachmentsThe20unhealthy20state20of20homelessness20FINALpdf

Lane R (2005) ldquoThe road to recovery ndash a feasibility study into homeless intermediate carerdquoHomeless Intermediate Care Steering Group Lambeth PCT London December available at wwwhousinglinorguk_assetsResourcesHousingHousing_adviceThe_Road_to_Recovery_-_A_feasibility_study_into_homelessness_and_intermediate_care_December_2005pdf


Lowson K and Hex N (2014) ldquoEvaluation of Bradford Homeless Health Interventionsrdquo Health EconomicConsortium York

NHCHC (2016) ldquoStandards for medical respite programsrdquo National Health Care for the Homeless CouncilOctober available at wwwnhchcorgwp-contentuploads201109medical_respite_standards_oct2016pdf

Pathway (2012) ldquoPathway Medical Respite Centre Executive Summaryrdquo available at wwwpathwayorgukwp-contentuploads201302PATHWAY_EXEC_FINALpdf (accessed 9 December 2018)

Pathway (2013) ldquoMedical Respite for Homeless People Outline Service Specificationrdquo May available atwwwpathwayorgukwp-contentuploads201305Pathway-medical-respite-for-homeless-people-0301pdf (accessed 9 December 2018)

Podymow T Turnbull J Tadic V and Muckle W (2006) ldquoShelter-based convalescence for homelessadultsrdquo Canadian Journal of Public Health Vol 97 No 5 pp 379-83

Project London (2014) ldquoRegistration refused a study on access to GP registration in Englandrdquo available athttpsuploadsdoctorsoftheworldorg20170727210522RegistrationRefusedReport_Mar-Oct2015pdf(accessed 9 December 2018)

Roos L Mota N Afifi T Katz L Distasio J and Sareen J (2013) ldquoRelationship between adversechildhood experiences and homelessness and the impact of Axis I and II disordersrdquo American Journal ofPublic Health Vol 103 No S2 pp S275-81

Story A (2013) ldquoSlopes and cliffs comparative morbidity of housed and homeless peoplerdquo The LancetVol 382 Special Issue pp S1-105

Thomson E (2017) ldquoPiloting a medical respite service for homeless patients at University College LondonHospitals Pathwayrdquo available at wwwpathwayorgukwp-contentuploads201305Pathway-To-Home-Summarypdf (accessed 9 December 2018)

Thomson E and Dorney-Smith S (2018) ldquoA needs assessment for homeless medical respite provision inNorth Central Londonrdquo December

van Laere I deWit M and Klazinga K (2009) ldquoShelter-based convalescence for homeless adults in Amsterdama descriptive studyrdquo BMC Health Services Research Vol 9 No 208 doi 1011861472-6963-9-208

van Tilburg Y Mantel T and Slockers MT (2008) ldquoIntermediate care for the homeless in RotterdamrdquoEuropean Network of Homeless Health Workers (ENHW) Vol 8 pp 7-8

Whiteford M and Simpson G (2015) ldquoA codex of care assessing the Liverpool hospital admissionand discharge protocol for homeless peoplerdquo International Journal of Care Coordination Vol 18 Nos 2-3pp 51-6 doi 1011772053434515603734

Zerger S Doblin B and Thompson L (2009) ldquoMedical respite care for homeless people a growing nationalphenomenonrdquo Journal of Health Care of the Poor and Underserved Vol 20 No 1 pp 36-41 doi 101353hpu00098

Further reading

Nyiri P (2012) ldquoA specialist clinic for destitute asylum seekers and refugees in Londonrdquo British Journal ofGeneral Practice Vol 62 No 604 pp 599-600

OrsquoCarroll A OrsquoReilly F and Corbett M (2006) ldquoHomelessness health and the case for an intermediate carecentrerdquo Mountjoy Street Family Practice Dublin

Office of the Chief Analyst (2010) ldquoHealthcare for single homeless peoplerdquo Department of Health London availableat wwwdhgovukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidanceDH_114250

About the authors

Samantha Dorney-Smith (Nursing Fellow Pathway) is Specialist Practitioner (Practice Nursing) andNurse Prescriber Sam has over 15 yearsrsquo experience working in inclusion health as Clinician andService Manager In 2005 she undertook a pilot of the Community Matron Model with homelesspatients before going on to deliver the Lambeth Homeless Intermediate Care Pilot Project in 2009More recently in 2014 Sam set up the Kings Health Partners Pathway Homeless Team the largestteam of its kind in the UK working across three NHS Trusts Sam now works for Pathway


undertaking service development service evaluation and research Sam is also Secretary of theLondon Network of Nurses and Midwives Homelessness Group Samantha Dorney-Smith is thecorresponding author and can be contacted at samanthadorney-smithnhsnet

Emma Thomson (Project Manager) has worked with Pathway since October 2013 She has over25 years of experience in public policy project management research evaluation and lecturingand was formerly Head of Strategy at the London Development Agency Emmarsquos work focusseson making the case for and setting up homeless medical respite services in London She recentlyled the UCLH ldquoPathway to Homerdquomedical respite pilot project and also recently contributed to adetailed homeless medical respite needs assessment study for North Central London Emmaalso co-ordinates a Pathway project providing housing and immigration legal advice to homelesspatients across several London hospitals

Dr Nigel Hewett (Medical Director Pathway) is Expert in Homeless Healthcare for over 25 yearsNigel has been working with Pathway since its inception Nigel has unparalleled experiencefounding Leicester Single Homeless multi-disciplinary team and opening one of Englandrsquos busiesthomelessness teams at UCLH He was awarded an OBE for his work in 2006 Nigel nowfocusses on training and supporting doctors in his role as Secretary to the Faculty of Homelessand Inclusion Health and Medical Director of Pathway

Stan Burridge (Expert by Experience Project Lead Pathway) spent most of his childhood in theinstitutional care system and has significant personal experience of homelessness He gainedwork experience by volunteering and participated in and led many service user led initiatives andactions Stan has worked for Pathway for six years and leads on service user-focussed researchfor NHS partners and homeless sector organisations as well as delivering lectures for a numberof universities and other groups As Expert by Experience Lead Stan supports a cohort ofldquoExperts by Experiencerdquo to participate in a variety of research activities get their voices heard andmake real change in healthcare systems

Dr Zana Khan has been GPClinical Lead for the Kingrsquos Health Partners Pathway Homeless Teamat Guyrsquos and St Thomasrsquo Hospital since 2014 and South London and Maudsley Mental HealthTrust (SLaM) since 2015 She is also Clinical Fellow for Pathway developing online learning andpost graduate education in Homeless and Inclusion Health with UCL She was appointedHonorary Senior Lecturer at UCL in October 2017 and lectures at conferences and teaches GPsGP trainees and junior doctors on Homeless and Inclusion Health as part of their runningeducational programmes Zana continues to work in homeless and mainstream General Practicein Hertfordshire and is GP Appraiser in London and Hertfordshire



The Cottage providing medical respitecare in a home-like environment forpeople experiencing homelessness

Angela Gazey Shannen Vallesi Karen Martin Craig Cumming and Lisa Wood

Abstract

Purpose ndash Co-existing health conditions and frequent hospital usage are pervasive in homeless populationsWithout a home to be discharged to appropriate discharge care and treatment compliance are difficultThe Medical Respite Centre (MRC) model has gained traction in the USA but other international examplesare scant The purpose of this paper is to address this void presenting findings from an evaluationof The Cottage a small short-stay respite facility for people experiencing homelessness attached to aninner-city hospital in Melbourne AustraliaDesignmethodologyapproach ndash This mixed methods study uses case studies qualitative interview dataand hospital administrative data for clients admitted to The Cottage in 2015 Hospital inpatient admissions andemergency department presentations were compared for the 12-month period pre- and post-The CottageFindings ndash Clients had multiple health conditions often compounded by social isolation and homelessnessor precarious housing Qualitative data and case studies illustrate how The Cottage couples medical care andsupport in a home-like environment The average stay was 88 days There was a 7 per cent reduction in thenumber of unplanned inpatient days in the 12-months post supportResearch limitationsimplications ndash The paper has some limitations including small sample size datafrom one hospital only and lack of information on other services accessed by clients (eg housing support)limit attribution of causalitySocial implications ndash MRCs provide a safe environment for individuals to recuperate at a much lower costthan inpatient admissionsOriginalityvalue ndash There is limited evidence on the MRCmodel of care outside of the USA and the findingsdemonstrate the benefits of even shorter-term respite post-discharge for people who are homeless

Keywords Australia Homelessness Emergency department Hospital use Medical respite careMedical respite centre


Background

The revolving door between homelessness and the health system is evident in many developedcountries (Fazel et al 2008 2014) and Australia is no exception The high prevalence ofco-occurring physical mental health and substance use issues (Fazel et al 2008 2014) andmultiple complex health conditions among people experiencing homelessness contributes tofrequent use of health services (Moore et al 2010 Fazel et al 2014) Engagement with primarycare providers and chronic disease management is also impeded by life on the street hencepeople experiencing homelessness frequently present to hospitals and emergency departments(ED) in crisis when their health has deteriorated to a life-threatening state (Fazel et al 2014Jelinek et al 2008 Weiland and Moore 2009)

Homelessness and unstable housing present significant challenges to the appropriatedischarge of patients from hospital (Greysen et al 2013) Even if crisis or temporaryaccommodation is available it is difficult to get the rest recuperation and follow-up careneeded and these challenges are compounded when people are surviving day to day on the

The authors would like to thankRebecca Howard AndrewHannaford and Una McKeever fromSt Vincentrsquos Hospital Melbourne fortheir assistance in the extraction ofhospital data and logisticalassistance in coordinatinginterviews The authors would alsolike to thank The Cottage staff staffof St Vincentrsquos Hospital Melbourneand externals stakeholders andCottage clients who participated instaff stakeholder and clientinterviews Finally the authors wouldlike to acknowledge the authorsrsquoco-researchers Kaylene ZaretzkyLeanne Lester and Paul Flatauwho were involved in the originalevaluation this paper was drawnfrom

Angela Gazey is GraduateResearch Assistant at TheUniversity of Western AustraliaPerth AustraliaShannen Vallesi is based at theCentre for Social Impact TheUniversity of Western AustraliaPerth AustraliaKaren Martin is based at TheUniversity of Western AustraliaPerth AustraliaCraig Cumming is ResearchFellow and Lisa Wood isAssociate Professor both atThe University of WesternAustralia Perth Australia


streets (Buchanan et al 2006) Meeting the basic practical requirements for treatmentcompliance can be problematic with hygienic wound care lack of places to wash and noaccess to refrigeration or secure storage for medications among obstacles often encountered(National Academies of Sciences and Medicine 2018)

For individuals experiencing homelessness being ldquodischarged homerdquo is an oxymoron There arefew suitable post-discharge locations and temporary and transitional housing providers are oftenunable to meet the needs of unwell or injured patients (Greysen et al 2013 Zerger et al 2009)Consequently patients experiencing homelessness face either longer inpatient admissions inexpensive acute care beds or are discharged when too unwell for the challenges of surviving onthe street resulting in high rates of unplanned re-admissions (Kertesz et al 2009 Doran RaginsIacomacci Cunningham Jubanyik and Jenq 2013) One innovative solution to this however isthe concept of medical respite centres (MRCs) that originated in the USA and is now gainingtraction internationally

An MRC provides stable accommodation and support to people who are homeless and haveacute or sub-acute care needs but do not require inpatient care (Doran Ragins Gross andZerger 2013 Buchanan et al 2006) The MRC model of care was initiated by the BostonHomeless Healthcare Program in 1993 when they opened Barbara McInnis House to addressthe challenges of providing appropriate pre-admission and post-discharge care to homelesspatients (Boston Health Care for the Homeless Program 2014) The connection and rapportestablished during care at an MRC also allows staff to link clients with community-basedsupport and primary care services (Zur et al 2016 Park et al 2017 Biederman et al 2014)Zur et al (2016) conducted in-depth qualitative interviews at an MRC in the USA and found thatboth clients and staff identified support in navigating the healthcare system overcoming logisticalchallenges and establishing trusting relationships as the most important aspects of the serviceThe provision of assistance to meet health goals and support to attend appointments has alsobeen identified by clients as key desired features of MRCs (Park et al 2017) Although theethos of all MRCs is similar they vary in services provided duration of stay possible and locationsome are co-located with healthcare facilities and have their own nursing staff or healthpractitioners whilst other MRC clients may receive in-reach support from hospital services(Buchanan et al 2006 Doran Ragins Gross and Zerger 2013)

Published studies on MRCs are in their infancy but evidence is mounting for the capacity ofMRCs to improve health outcomes for clients and potentially reduce ED and inpatientadmissions Reductions in hospital re-admissions and ED presentations have been observedacross a number of studies examining the effects of MRCs on patientsrsquo health outcomes in theUSA (Doran Ragins Gross and Zerger 2013 Zerger et al 2009 Zur et al 2016 Buchananet al 2006) and a pilot study in the UK (Homeless Link and St Mungorsquos 2012) A cohort study ofhomeless patients who had been supported by an MRC where the average length of stay was42 days found that in the 12-months after initial discharge patients had 58 per cent fewerinpatient days a 49 per cent reduction in inpatient admissions and a 36 per cent reduction in EDpresentations compared to the control group of patients who had not accessed MRCs(Buchanan et al 2006) The MRC model of care has been expanded in the USA with 78 MRCsnow existing across 30 states (National Health Care for the Homeless Council 2016)

While there is keen interest in the MRC model among those working in homeless healthcare inother countries examples outside of the USA remain sparse In 2012 Pathway produced acompelling feasibility case for an MRC for homeless patients in London (Pathway UK 2012) butto our knowledge this has not yet been funded In Australia there are two small respite centresoperating under the auspice of St Vincentrsquos Health Australia (Tierney House at St VincentrsquosHospital Sydney and the Sister Francesca Healy Cottage (The Cottage) at St Vincentrsquos HospitalMelbourne (SVHM) A submission for an MRC in Western Australia was recently submitted to theState Government as part of a review into strategies for a more sustainable health system(Department of Health Western Australia 2017)

This paper is based on a recent evaluation of The Cottage an MRC attached to SVHM aninner-city hospital with an ethos of providing high quality care to the most disadvantaged groupsin Melbourne (Wood et al 2017) The SVHM campus is located in close proximity to manyhomelessness services and sees a large proportion of the people experiencing homelessness in


inner-city Melbourne The Cottage is a small six-bed respite facility providing a stable environmentfor people who are homeless or at risk of homelessness to receive acute nursing careand support post-hospital discharge (Wood et al 2017) It occupies a re-purposed cottage andprovides a home-like environment adjacent to the main SVHM hospital enabling prompt hospitaltreatment if necessary The Cottage is staffed by nursing and personal care staff Part ofThe Cottage remit is to link clients to with other community-based support services and assist inobtaining more permanent accommodation (Wood et al 2017)

Aims

The aims of this research were to describe the health profile of clients supported by The Cottageexamine clientsrsquo patterns of hospital service use and the type of support they were provided andexplore service provider and client perceptions of support provided by The Cottage In additionthis paper examines patterns of clientsrsquo hospital service utilisation in the 12-months prior and12-months following their first admission to The Cottage in 2015

Methods

These results have been drawn from a larger mixed methods evaluation of four SVHMhomelessness services that was undertaken in 2016 (Wood et al 2017) The full evaluationcomprised qualitative in-depth interviews with staff stakeholders and clients of the services andanalysis of quantitative hospital administrative data Approval to conduct this research wasgranted by the Victorian State Single Ethical Review Human Research Ethics Committee (HREC)(reference HREC16SVHM114) and St Vincentrsquos Hospital Melbourne HREC (reference HREC-A08616) on the 18 July 2016 with reciprocal ethics approval granted by the University of WesternAustralia HREC on the 16 August 2016 (reference RA418577)

Qualitative data and analysis

In-depth interviews were conducted with five clients three employees and 40 key internal andexternal stakeholders A purposive sampling method was used to guide the recruitment of clientparticipants that reflected the diverse demographic backgrounds and differing health andpsychosocial needs seen at The Cottage and included a mix of clients who had received supportfrom both ALERT and The Cottage and The Cottage only Quotes presented in this paper arerelated to experiences and service delivery at The Cottage Interviews were semi-structured andprobed clientsrsquo experiences of The Cottage support received and issues experienced

Interviews were audio recorded and data was transcribed verbatim and coded using QSR NViVo(QSR International Pty Ltd 2011) Thematic analysis using inductive category development andconstant comparison coding (Glaser 1965) was undertaken with cross checking between teammembers to enhance validity and minimise bias

Quantitative data and analysis

Quantitative data on hospital service utilisation at SVHM were provided for clients supported byThe Cottage during the 2015 calendar year (nfrac14 139) This included clients whose episode of carecommenced in 2014 but continued into 2015 Data on ED presentations and unplanned inpatientadmissions were extracted from the Patient Administration System database and linked toanonymous client ID numbers before being provided to the research team for analysis

The analysis for this paper explores hospital use in the 12-months prior to each clientrsquos firstepisode start date in 2015 and 12-months post their episode start date The ldquopostrdquo periodreferred to in this paper includes the period of time during which clients received support from TheCottage Clients who died less than 12-months post support (nfrac14 4) were excluded from analysisSome clients of The Cottage (nfrac14 33) also received support from ALERT (a SVHM casemanagement programme for frequent users of hospital services) and therefore the hospitalservice utilisation results have been presented for the total group (all clients of The Cottage) thesub-group (nfrac14 102) of clients who received support from The Cottage only and the sub-group


(nfrac14 33) who received support from both The Cottage and ALERT Distribution of hospitalutilisation data both 12-months before and after first episode of care for The Cottage was notnormally distributed so Wilcoxon signed-rank tests were used to compare the data for eachperiod Stata version 140 (StataCorp 2015) was used for the analysis

Client case studies

Client case studies provide important context for hospital service utilisation amongst the clientgroup and help to capture a richer picture of clientsrsquo interaction with the health system and thenature of support provided through The Cottage The case studies include indicative estimates ofthe cost decrease associated with changes in ED presentations and unplanned inpatientadmissions for these clients in the 12-months post support The costs were calculated fromhospital cost data produced by the Independent Hospital Pricing Authority (IHPA) (Round 20)using the average cost of $1890 per day of inpatient admission (Independent Hospital PricingAuthority 2018) The IHPA provides an annual report based on data submitted by Australianpublic hospitals and is routinely used to estimate healthcare costs (Independent Hospital PricingAuthority 2018)

Results

Client demographics

Of the 139 clients supported by The Cottage in 2015 102 (75 per cent) were male with anaverage age of 54 (range 24ndash81 years) There were 96 clients (69 per cent) born in Australia andEnglish was the preferred language of 127 clients (91 per cent) When asked about their usualaccommodation 32 (23 per cent) of clients indicated that they were experiencing primaryhomelessness with the remainder living in tenuous and marginalised housing

The Cottage 2015 service delivery

During 2015 The Cottage provided 167 episodes of care (range 1ndash4 episodes per person) to 139individual patients Of the 139 clients supported 103 were supported by The Cottage only withthe other 36 supported by both The Cottage and by ALERT The majority (nfrac14 131) of individualsonly had a single episode at The Cottage during 2015 with the remaining eight clients havingmultiple episodes of care

Duration of episodes of care The average duration of an episode of care for patients attendingThe Cottage in 2015 was 88 days Over half of episodes (56 per cent nfrac14 94) lasted for oneweek or less whilst 44 per cent (nfrac14 73) of episodes were for a period of 8-14 days The Cottagealso had 29 episodes of care (17 per cent of episodes) which lasted for one night only

Health profile of Cottage clients

The patients accessing The Cottage had extremely complex health profiles and frequentlypresented to ED resulting in unplanned inpatient admissions (the quotation below) Many hadlong-term histories of contact with the hospital system

Clients who are admitted to The Cottage have a diverse range of health care needs The mostcommon reasons for admission during the study period were for post-operative care following anon-orthopaedic procedure and mental or behavioural disorders caused by AOD use Clients ofThe Cottage had on average 11 psychosocial factors affecting their health (min 1 max 22) Themost common were daily living issues (85 per cent) carer issues (75 per cent) and social isolation(74 per cent) The complexity of Cottage patients is further illustrated through the case studybelow (the quotation below)

Complexity of Inpatient Admissions for Cottage Clients

A male in his early forties with a history of alcohol dependence and depression had four separate staysat The Cottage in the 2015 calendar year but has previously had multiple complex presentations to


SVHM since first presenting in 2006 In April 2015 he was admitted for post-detox respite and thensupported by the ALERT team for ongoing support and case management over a 13-month period(until May 2016) Since 2015 he has had at least fortnightly contact with SVHM (either through the EDor as an outpatient) These presentations are usually for intoxication injuries sustained whileintoxicated overdose or self-harm related Additionally he has had multiple inpatient admissions foralcohol withdrawal and liver damage between 2015 ndash April 2017 he had 38 inpatient admissions tovarious units including emergency short stay psychiatry and general medicine

Changes in hospital service utilisation post support from The Cottage

Changes in hospital service utilisation after receiving support from The Cottage in 2015are presented for all Cottage clients excluding those who died less than 12-monthspost-support (nfrac14 4)

ED presentations The number of clients who presented to ED decreased in the year followingsupport from The Cottage compared to the year prior (Table I) While there was an increase in thetotal number of ED presentations in the 12-months prior to post service contact (from 304 to356 presentations) this was not significant and masks variability in the patterns of ED presentationamong clients Overall in the year after commencing an episode of care at The Cottage 36 per cent(nfrac14 49) of clients had a reduction in the number of ED presentations 32 per cent (nfrac14 43) had no

Table I ED presentations and unplanned inpatient admissions 12-months before and 12-months after first episode of care atThe Cottage

The Cottage (nfrac14102) ALERTThe Cottage (nfrac1433) Total (nfrac14 135)

ED presentations12-months beforeTotal ED presentations 146 158 304Average number of ED presentations per person (SD)a 14 (19) 48 (84) 225 (47)Median presentations 1 2 1Range in number of presentations per person 0ndash8 0ndash47 0ndash47Total people presenting to ED ( of group) 58 (57) 29 (88) 87 (64)

12-months afterTotal ED presentations 179 177 356Average number of ED presentations per person (SD)a 18 (34) 54 (89) 26 (55)Median presentations 1 2 1Range in number of presentations per person 0ndash28 0ndash46 0ndash46Total people presenting to ED ( of group) 57 (56) 23 (70) 80 (59)

Unplanned inpatient admissions12-months beforeTotal inpatient admissions 95 71 166Average number of inpatient admissions per person (SD)a 09 (14) 21 (29) 12 (19)Median admissions 0 1 1Range in number of inpatient admissions per person 0ndash6 0ndash13 0ndash13Total people admitted as inpatients ( of group) 48 (47) 26 (79) 74 (55)Total days admitted 543 304 847Average days admitted per person (SD) 53 (96) 92 (107) 63 (100)Median days 0 4 2

12-months afterTotal inpatient admissions 88 83 171Average number of inpatient admissions per person (SD)a 09 (15) 25 (49) 13 (28)Median admissions 0 1 0Range in number of inpatient admissions per person 0ndash8 0ndash25 0ndash25Total people admitted as inpatients 43 (42) 18 (55) 61 (45)Total days admitted 566 221 787Average days admitted per person (SD) 55 (147) 67 (139) 58 (145)Median days 0 1 0

Notes aAverage unplanned admissions were calculated over whole sub-sample including those who did not present in the specified periodpfrac14005


change and 32 per cent (nfrac14 43) had an increase The overall increase in total ED presentation in thepost period was attributable to 43 individuals with four clients having an increase of 11 or more EDpresentations in the 12-month period

Inpatient admissions and length of stay There was a significant decrease of 7 per cent in the totalnumber of unplanned inpatient admission days (from 847 to 787 days) that clients were admittedfor at SVHM in the 12-months following support compared to the 12-months prior to their firstepisode of care at The Cottage (Table I) There was also a reduction in the proportion of clientsadmitted (18 per cent) as inpatients in the 12-months after receiving an episode of care from TheCottage For those patients who were admitted their average number of inpatient admissions didnot significantly change in the post-support period but notably the average duration ofadmission was shorter (from 63 to 58 days) (Table I) As with ED presentation variability therewas substantial variation in inpatient admission patterns among individual clients in the 12-monthperiod after they were supported by The Cottage Overall 42 per cent (nfrac14 57) of clients had areduction in inpatient days 32 per cent (nfrac14 43) had no change and 26 per cent (nfrac14 35) had anincrease in inpatient days

Case studies

This evaluation was mixed methods and it is recognised that hospital service utilisation datadoes not capture the full picture of clientsrsquo interaction with the health system nor the nature ofsupport provided by The Cottage The following case studies (the quotation below) provideadditional insight into the type of support provided by The Cottage and how this potentiallycontributed to changes in hospital service use Additionally indicative estimates of theeconomic impact of changes in clientsrsquo service use in the year following support from TheCottage have been provided

Case studies for clients with reductions and increases in inpatient days

Case study 1 client supported to engage with appropriate health services

A man in his late sixties was living alone in public housing when he had a heart attack resulting in aone-month inpatient admission in the cardiology ward He was discharged to the Cottage for 14 dayswhere he was supported in his physical rehabilitation and given education on the management of hiscondition including the use of blood thinning medication and the necessity of regular blood testingDuring his time at The Cottage the client received support from the Department of Addition Medicine atSVHM and agreed to have ongoing drug and alcohol support when he was discharged He alsoengaged with heart failure nurses who provided further education and established a care plan with theclient The Cottage provided a dosette box to assist the client in self-managing his medication Afterdischarge the client continued to receive support from the heart failure rehabilitation team andattended a heart failure rehabilitation program in both 2015 and 2016 The clientrsquos successfulmanagement of his condition facilitated through support provided from The Cottage and cardiacrehabilitation teams resulted in a substantial reduction in hospital inpatient admissions In the 12months after receiving support from The Cottage the client had one planned hospital admission to fitan implantable defibrillator and spent 38 fewer days as an inpatient than in the year before he wassupported by The Cottage This reduction in inpatient days resulted in a cost decrease of $71820(Independent Hospital Pricing Authority 2018)

Case study 2 client assisted to stabilise health conditions and navigate services

An Aboriginal woman in her early sixties had a three-week stay at The Cottage to treat multiple healthissues stemming from injecting drug use Prior to her admission to The Cottage she had extensiveinpatient admissions as injecting drug use had caused bacterial blood infection and hip and spinalabscesses During her admission at The Cottage she received IV antibiotics blood tests andmethadone administration Staff at The Cottage assisted the client to navigate the health systemand arranged for her to have physiotherapy to assist her mobilisation and rehabilitation After herhealth had stabilised she was discharged to stay with her daughter whilst awaiting public housingaccommodation In the 12-months after support from the Cottage she spent substantially lesstime admitted as an inpatient a reduction of 33 days compared to the previous year This reductionin inpatient admission days is associated with a cost decrease of $62370 (Independent HospitalPricing Authority 2018)


Case Study 3 client with complex mental health issues and increase in inpatient admissions

A client in his early forties was socially isolated with health issues including schizo-affective disorderhepatitis C and thyroid dysfunction He was admitted to the Cottage for three days to have pre and postcare following a colonoscopy and was subsequently discharged home His mental health continued tobe unstable despite community mental health support and he had an extended psychiatric admission of91 days after which he was discharged to a residential psychiatric facility This admission resulted in anincrease of 91 inpatient days compared to the 12 months prior to support from The Cottage

Qualitative client staff and stakeholder perceptions of The Cottage

Qualitative interview data helps to describe the way in which The Cottage supports clients in anon-clinical respite environment Key themes that emerged through the qualitative analysisincluded the importance of The Cottage culture and environment the significance of The Cottagein enabling clients to receive appropriate care and the role of The Cottage in assisting clients tonavigate the healthcare system and engage with mainstream health services

The caring ethos of The Cottage was emphasised by numerous staff members stakeholders andclients A dominant theme was the genuine compassion and empathy that infuses The Cottageculture and the way in which this lubricates forming connections with clients This wasconsidered particularly important in light of the high levels of loneliness and social isolationexperienced by clients The non-clinical physical environment of an MRC also emerged as acritical factor with the home-like environment of The Cottage enabling people to have socialcontact and support (from staff and others) whilst creating a space for clients to retreat to

Within a hospital setting it would be different to the relationships you form within The Cottage(Service staff )

This is more homely Itrsquos ndash you feel like yoursquore part of a family or yoursquore at home or something (Client)

Itrsquos nothing like a hospital facility I wouldnrsquot describe it as anything like a hospital facility Itrsquos totallydifferent (Client)

The role of The Cottage in assisting clients to navigate the health system was anotherkey theme emerging from the interviews with staff stakeholders and clients The Cottage wasseen as a place where positive relationships with staff were formed while clientsrsquo healthissues were stabilised and trust established to facilitate successful referrals back to themainstream health system

The purpose of The Cottage as I see it is to be able to provide equitable health care for people that arehomeless that may ordinarily struggle navigating their way through the health system I think ourpurpose is to help people receive the health care that they deserve and embrace the challenges toachieve this (Service staff )

Staff at The Cottage and in the wider hospital acknowledged that people who are homeless cansometimes find hospital settings intimidating and may have had negative experiences of healthinstitutions in the past Consequently The Cottage was seen to play a valuable role insupporting clients to re-engage with the health system As such staff suggested that increasesin hospital use by some clients following attendance at The Cottage is not necessarily anegative outcome as it can reflect an increased trust of health services and willingness to seekappropriate treatment

Sometimes their hospital contacts might actually go up because their trust of services is betterbecause we have built up trust and a relationship with them The other thing that we havenrsquotmeasured and could be an option is that yes they may well re-present but is their episode of careshorter (Service staff )

A client discussed how they would usually avoid hospitals but that the coordination between staffat The Cottage and SVHM had made it easier for them to attend dialysis appointments

Like itrsquos a real good hospital if yoursquove got to go into hospital but Irsquom not really a hospital personWhatever I can do Irsquoll stay away from there So if I can go to The Cottage it makes it a whole lot easier[hellip] Like even when Irsquomat The Cottage and that and Irsquove got to come to dialysis everythingrsquos arrangedUsually Irsquove got ndash they even walk me back to The Cottage yeah most times (Client)


Staff also identified multiple instances where support provided through The Cottage had made asubstantial difference to clientsrsquo outcomes and enabled them to access care that they wouldotherwise have been unable to receive due to lacking suitable home environments forpreparation for or recovery from medical treatment For these clients The Cottage is a stableplace for this necessary phase of care and provides a stable location to complete assessmentsand appropriate referrals during clientsrsquo recovery (see case studies 1 and 2)

We will organise things like booking them into The Cottage the night before so that they can do their[bowel prep] or their fasting or whatever needs to be done You know expecting someone whorsquoshomeless to get to a pre-admission clinic at nine orsquoclock thatrsquos been arranged through the ED is almostimpossible (Service staff )

Wersquove had a couple of clients that come to dialysis as our patients and then they did some respiteThey needed to be admitted and so theyrsquove actually admitted them into The Cottage for a period oftime Allows them to still continue dialysis and we get to actually do a mental health assessment(Internal stakeholder)

Discussion

There is increasing pressure on hospitals around the world to reduce costly bed occupancythrough earlier discharge and ldquohome-basedrdquo care but homelessness presents significantmedical social and ethical challenges to hospital systems in this regard (Zerger et al 2009)Moreover as articulated by Hewett and colleagues the care delivered to patientsrsquo experiencinghomeless can be considered an ldquoacid testrdquo for the whole health system (Hewett et al 2013)

The MRC model addresses many of these dilemmas offering a safe space for post-hospitalrecuperation and follow-up care that can reduce the likelihood of re-presentation and enableother health psychosocial and housing issues to be addressed (Buchanan et al 2006 Zergeret al 2009) The complex multi-morbidities of people who are homeless means that a short-termepisode of care in a MRC is not a ldquomagic bulletrdquo However as shown in this evaluation study ofThe Cottage even a small respite facility can make a significant difference to the post-dischargecare and recovery of patients experiencing homelessness

There is limited published literature outside of the USA that contributes to the evidence base forMRCs with the present study a notable exception The 7 per cent reduction in unplanned inpatientdays in the 12-months following support from The Cottage builds upon international evidence thatMRCs can stabilise clientsrsquo health and reduce the burden on the health system (Doran RaginsGross and Zerger 2013) Whilst the magnitude of reduction in inpatient days was smaller than thatobserved in the most cited MRC studies from the USA it is pertinent to note that The Cottage is ashorter term facility with an average length of stay of 88 compared to an average stay of over onemonth for other MRC models (Buchanan et al 2006 Doran Ragins Gross and Zerger 2013)

Consistent with the available published studies on MRCs (Buchanan et al 2006 Doran RaginsGross and Zerger 2013) we found that there was a decrease in the proportion of clients whopresented to ED andwhowere admitted as inpatients to SVHM in the 12-months following admissionat TheCottage However clients that continued to utilise hospital services did somore frequently withincreases in the number of ED presentations per client A longer follow-up period is warranted forfuture studies with an evaluation of Tierney House (a short-term small bed respite facility at StVincentrsquos Sydney) reporting that clientsrsquo hospital service use initially increased but as healthconditions stabilised acute health service use was lower at two-year follow up (Conroy et al 2016)

The Cottage clients had highly complex health and psychosocial needs and the prevalence ofclients with trimorbid and chronic health conditions is consistent with the patient profile of MRCsinternationally (Doran Ragins Gross and Zerger 2013 Buchanan et al 2006) Due to thiscomplexity once-off short episodes of care at The Cottage cannot be considered as a panaceato the challenges experienced by clients Changes in clientsrsquo social housing and healthcircumstances are all factors beyond the influence of The Cottage that can impact on wellbeingand hospital use The high burden of chronic health conditions among clients seen atThe Cottage may explain some of the increases observed in the number of ED presentations andinpatient admissions among some of the cohort Mental illness has been shown elsewhere


to be a key driver of extended hospital admissions among people who are homeless(Stafford and Wood 2017) and this accounted for the very lengthy admission in case study 3

Congruent with qualitative findings reported by Zerger et al (2009) Zur et al (2016) andPark et al (2017) in the USA The Cottage was viewed by clients and stakeholders as providingan important period of stability enabling staff to build trusting relationships that increased clientsknowledge and capacity to manage their own health Social isolation was noted in theclinical records of a number of the case studies presented in our paper highlighting the criticalrole of places such as The Cottage as a conduit for social interaction and support during a periodof high vulnerability post-discharge

Being able to discharge patients who are homeless to an MRC facility is a far lesscostly alternative to keeping them in acute hospital beds (Pathway UK 2012 Doran RaginsGross and Zerger 2013) or dealing with the sequelae of discharge to rough sleeping ortransitional accommodation The average inpatient day for a Melbourne hospital in 20152016was $1890 (Independent Hospital Pricing Authority 2018) compared with an estimated averagecost per day of care of $505 at The Cottage in 2015 (Wood et al 2017) Additionally as shown incase studies 1 and 2 reductions in hospital use following care at The Cottage can potentially freeup hospital beds and yield a cost saving for the health system The economic rationale for thecost effectiveness of MRCs is clearly articulated in the Pathway UK (2012) proposal for a MRC inLondon and calls for a MRC in Western Australia (Department of Health Western Australia 2017)

Limitations

As with any evaluation of a real-world intervention this study is not without its limitations Hospitaldata were only available for SVHM and given the itinerant nature of the homeless population EDpresentations and inpatient admissions at other hospitals were not able to be captured Whilstinterviews with homelessness service providers indicated that SVHM is often the default hospitalfor their clients it is noted that clients in The Cottage cohort in this study may have used otherhospitals and health services This could impact the reported change in hospital serviceutilisation resulting in either an under or overstatement of the actual change

The study was also not able to capture nor control for other interventions that homeless clients mayhave accessed that could have impacted on health andor the underlying social determinants ofhealth Data on housing status and how this changed over the two-year period would be a powerfuladdition to studies of MRCs given amassing evidence for the critical role of housing in tackling theenormous health disparities associated with entrenched homelessness (Stafford and Wood 2017)People who are homeless often accessmultiple support services and clients of The Cottagemay havebeen accessing other support services pre- post- and simultaneously to their period of support suchas the 39 clients who were also supported by ALERT It is therefore not possible to directly attributechanges in health service utilisation and client outcomes to support provided through The Cottage

The small sample size in our study may have resulted in limited ability to detect all changes inhospital and ED use before and after use of The Cottage Similarly the study period is relativelyshort with other studies not detecting significant changes until the 24-month mark (Conroy et al2016) so it is not possible to observe longer term trends using the available data

Conclusions

Services such as The Cottage have an important role in the appropriate discharge and post-hospital care of patients experiencing homelessness and have the potential to reduce the burdenon health systems Overall while only the reduction in unplanned inpatient admissions days wassignificant the narrative of two of the client case studies and qualitative findings support theexisting evidence on the benefits of MRCs in reducing hospital service utilisation providingstability follow-up care increased knowledge and capacity and establishment of trustingrelationships for clients Our study has demonstrated that even short stay MRCs can have animpact on clientsrsquo future hospital service utilisation Future research could utilise case-controlstudy designs to investigate outcomes amongst patients who have accessed MRCs comparedto similar patients who had not accessed this support


References


Boston Health Care for the Homeless Program (2014) ldquoMedical respite carerdquo available at wwwbhchporgpatient-servicesmedical-respite-care (accessed 20 July 2018)


Conroy E Bower M Kadwell L Reeve R Flatau P and Mischenko D (2016) St Vincentrsquos HospitalrsquosHomeless Health Service ldquoBridging of the Gaprdquo between the Homeless and Health Care Western SydneyUniversity Sydney

Department of Health Western Australia (2017) Sustainable Health Review Public Submission StBartholomewrsquos House Government of Western Australia Department of Health Perth

Doran K Ragins K Gross C and Zerger S (2013) ldquoMedical respite programs for homeless patients asystematic reviewrdquo Journal of Health Care for the Poor and Underserved Vol 24 No 2 pp 499-524

Doran K Ragins K Iacomacci A Cunningham A Jubanyik K and Jenq G (2013) ldquoThe revolving hospitaldoor hospital readmissions among patients who are homelessrdquo Medical Care Vol 51 No 9 pp 767-73


Fazel S Khosla V Doll H and Geddes J (2008) ldquoThe prevalence of mental disorders among the homelessin western countries systematic review and meta-regression analysisrdquo PLoS Med Vol 5 No 12 pp 1670-81

Glaser BG (1965) ldquoThe constant comparative method of qualitative analysisrdquo Social Problems Vol 12 No 4pp 436-45

Greysen R Allen R Rosenthal M Lucas G andWang E (2013) ldquoImproving the quality of discharge carefor the homeless a patient-centered approachrdquo Journal of Health Care for the Poor and Underserved Vol 24No 2 pp 444-55

Hewett N Bax A and Halligan A (2013) ldquoIntegrated care for homeless people in hospital an acid test forthe NHSrdquo British Journal of Hospital Medicine Vol 74 No 9 pp 484-5

Homeless Link and St Mungorsquos (2012) Improving Hospital Admission and Discharge for People Who areHomeless Homeless Link and St Mungorsquos London

Independent Hospital Pricing Authority (2018) ldquoNational hospital cost data collection cost report round 20financial year 2015-16 ndash February 2018rdquo Independent Hospital Pricing Authority Canberra

Jelinek G Jiwa M Gibson N and Lynch A-M (2008) ldquoFrequent attenders at emergency departments alinked-data population study of adult patientsrdquo Medical Journal of Australia Vol 189 No 10 pp 552-6

Kertesz S Posner M Orsquoconnell J Swain S Mullins A Shwartz M and Ash A (2009) ldquoPost-hospitalmedical respite care and hospital readmission of homeless personsrdquo Journal of Prevention amp Intervention inthe Community Vol 37 No 2 pp 129-42

Moore G Gerdtz MF Hepworth G and Manias E (2010) ldquoHomelessness patterns of emergencydepartment use and risk factors for re-presentationrdquo Emergency Medicine Journal Vol 28 pp 422-7

National Academies of Sciences and Medicine (2018) Permanent Supportive Housing Evaluating theEvidence for Improving Health Outcomes among People Experiencing Chronic Homelessness The NationalAcademies Press Washington DC

National Health Care for the Homeless Council (2016) 2016 Medical Respite Program Directory Descriptionsof Medical Respite Programs in the United States National Health Care for the Homeless Boston MA

Park B Beckman E Glatz C Pisansky A and Song J (2017) ldquoA place to heal a qualitative focus groupstudy of respite care preferences among individuals experiencing homelessnessrdquo Journal of Social Distressand the Homeless Vol 26 pp 104-15

Pathway UK (2012) Pathway Medical Respite Centre A New Model of Specialist Intermediate Care for HomelessPeople Prospectus The Bartlett School of Construction Project Management University College London London


QSR International Pty Ltd (2011) ldquoNVivo qualitative data analysis softwarerdquo QSR International Pty Ltd

Stafford A and Wood L (2017) ldquoTackling health disparities for people who are homeless Start with socialdeterminantsrdquo International Journal of Environmental Research and Public Health Vol 14 No 12 pp 1535-47

StataCorp (2015) Stata Statistical Software Release 14 StataCorp LP College Station TX

Weiland T and Moore G (2009) ldquoHealth services for the homeless a need for flexible person-centred andmultidisciplinary services that focus on engagementrdquo InPsych the Bulletin of the Australian PsychologicalSociety Vol 31 No 5 pp 14-15

Wood L Vallesi S Martin K Lester L Zaretzky K Flatau P and Gazey A (2017) St Vincentrsquos HospitalMelbourne Homelessness Programs Evaluation Report An Evaluation of ALERT CHOPS The Cottage andPrague House Centre for Social Impact University of Western Australia Perth

Zerger S Doblin B and Tohmpson L (2009) ldquoMedical respite care for homeless people a growing nationalphenomenonrdquo Journal of Health Care for the Poor and Underserved Vol 20 No 1 pp 34-41

Zur J Linton S and Mead H (2016) ldquoMedical respite and linkages to outpatient health care providers amongindividuals experiencing homelessnessrdquo Journal of Community Health Nursing Vol 33 No 2 pp 81-9

About the authors

Angela Gazey is Graduate Research Assistant at the School of Population and Global HealthAngela completed her undergraduate Degree BSc (Hons) (Population Health and Law andSociety) at the University of Western Australia in 2017 She has a strong interest in improvinghealth and wellbeing for vulnerable and disadvantaged population groups with recent projectsfocussing on people experiencing homelessness Angela is passionate about research that hasreal-world relevance that supports services working with vulnerable groups on the groundAngela Gazey is the corresponding author and can be contacted at angelagazeyuwaeduau


Karen Martin research involves investigating strategies to improve the mental and physical healthof vulnerable and disadvantaged populations Over the last 20 years Karen has undertakenresearch within diverse health fields such as psychological and post-traumatic distress domesticviolence mental health loneliness and health in homeless and refugee populations She isexperienced in quantitative qualitative and mixed methods research and focusses on researchthat is relevant and applicable to policy and practice

Craig Cumming is early Career Researcher focussing on the health social and justice outcomesof socially disadvantaged people with a particular focus on drug and alcohol misuse and socialdisadvantage for people in contact with the justice system as well as people experiencinghomelessness He is currently completing a PhD Degree at the Centre for Health ServicesResearch in the School of Population and Global Health at the University of Western Australia

Dr Lisa Wood has nearly three decades of experience in public health and health promotion inWA nationally and internationally Dr Woodrsquos research is focussed on the need for moreupstream and join-up solutions to address complex social challenges such as homelessnessincarceration social isolation and closing the gap in Aboriginal wellbeing Her research has hadconsiderable traction with policy makers and government and non-government agencies andshe is highly regarded for her collaborative efforts with stakeholders to ensure research relevanceand uptake



Establishing a hospital healthcare team ina District General Hospital ndash transforminga model into a reality

Rose Isabella Glennerster and Katie Sales

Abstract

Purpose ndash The authorsrsquo interest in the discharge of patients with no fixed abode (NFA) arose throughrepeatedly seeing patients discharged back to the streets In 2017 the Royal United Hospital (RUH) treated155 separate individuals with NFA making up 194 admissions Given these numbers the best practiceaccording to Inclusion Healthrsquos tiered approach to secondary care services suggests that the hospital shouldbe providing a dedicated housing officer and a coordinated discharge pathway As this is currently lackingthe purpose of this paper is to establish a Homeless Healthcare Team (HHT) and design a hospital protocolfor the discharge of NFA patients with strong links into community supportDesignmethodologyapproach ndash The literature review identified six elements that make up a successfulHHT which has provided the structure for the implementation of the authorsrsquo model at the RUHFindings ndash Along the way the authors have faced a number of challenges whilst attempting to transform themodel into a reality including securing funding allocating responsibility balancing conflicting prioritiescoordinating schedules developing staff knowledge and challenging prejudice The authors are now workingcollaboratively with invested parties from the third sector specialist primary and secondary care healthservices and local government to overcome these barriers and work towards the long-term goalsOriginalityvalue ndash Scarce literature exists on the practicalities of attempting to set up an HHT in a DistrictGeneral Hospital The authors hope that the documentation of the authorsrsquo experience will encourage othersto broaden their horizons and persist through the challenges that arise

Keywords Homeless Hospital Discharge District General NFA Secondary care

Paper type Case study

Introduction

The purpose of this contribution to this special issue on hospital discharge arrangements forhomeless people is to describe a project that aims to improve the care discharge and follow upof a vulnerable patient group namely individuals with no fixed abode (NFA) at the Royal UnitedHospital (RUH) Bath through establishing an effective Homeless Healthcare Team (HHT)

To achieve this a literature review was undertaken to determine what an effective HHT wouldlook like for a District General Hospital and what provisions (if any) were already in place

Ill health homelessness and the cost to the NHS

Socially excluded populations experience extreme health inequalities across a wide range ofhealth conditions (Aldridge et al 2017) They experience disproportionately higher rates ofdisease injury and premature mortality (Fazel et al 2014) In comparison to the slope of healthinequalities known to exist across the IMD classification of deprivation the homeless experiencehealth needs more akin to a cliff edge (Story 2013)

Long-term homelessness is characterised by ldquotri-morbidityrdquo ndash the combination of physical illhealth mental ill health and drug and alcohol misuse (Deloitte 2012) Exposure to lifestyle risk

The authorsrsquo thanks go toDr Pippa Metcalf who has been agreat encouragement and supportthroughout the journey inestablishing an HHT at the RUHwithout her this project would nothave got off the ground Theauthors would also like to thankChris Sargeant for his timedirection and advice Finally amassive thank you to the team atDHI namely David Walton ChrisHussey and Nik Brown for theircrucial input in securing a bid andthe time they have invested tomake this idea a reality

Rose Isabella Glennerster is aDoctor at the Royal UnitedHospitals Bath NHSFoundation Trust Bath UKKatie Sales is a Doctor at theBristol Royal Hospital forChildren Bristol UK


factors including alcohol smoking and drug use combined with poor nutrition harsh livingconditions victimisation (physical and sexual assaults) and unintentional injuries result in extrememorbidity and mortality This is potentiated by poor access to healthcare and challenges inadherence to medication (Department of Health (DoH) Office of the Chief Analyst 2010Healthcare for Single Homeless People)

In a 2010 paper the DoH estimated that homeless patients were five times more likely to attendAampE than their age-matched housed equivalents They are also three times as likely to beadmitted and have a three times length of stay resulting in eight times the cost This translates to acost of at least pound85m per annum (Homeless Link 2015) It is widely accepted that the survival ofthe NHS will depend on the integration and shared responsibility of health and social careservices Within healthcare there needs to be much stronger integration of primary andsecondary care services This is of particular importance in the case of socially deprived groups

Rationale and relevance of project

The number of people sleeping rough in Bath and North East Somerset (BANES) is on theincrease BANES has a higher rate of rough sleepers than most statistically similar authorities(Homelessness |Bathnes 2017) It has experienced a 36 per cent increase from 25 individualscounted on a single night in 2016 to 34 in November 2017 (XXXX 2018)

The RUH is a 759 bed District General Hospital serving a population of around 500000 people inBath and the surrounding area (Royal United Hospitals Bath 2014) In total 155 homelessindividuals attended the RUH in 2017ndash2018 Of these 151 came via AampE accounting for 503separate attendances and just under one-third of these attendances resulted in admission Intotal there were 194 admissions made up of 75 individuals with an average length of stay of 43days When comparing this to the three years earlier data (Homelessness Partnership |Bathnes2018) this represented a 12 per cent increase in individuals using the hospital and a 19 per centincrease in the number of patients admitted

Guidance from the DoH states that a protocol should be in place to prevent the discharge ofpatients to the streets or other inappropriate locations (Office of the Chief Analyst 2010) TheRoyal College of Physicians (2013) has endorsed the homeless and inclusion health standardsproduced by the Faculty for Homeless and Inclusion Health These standards have demonstratedimproved patient care and cost efficiency (Faculty for Homeless and Inclusion Health 2018)Having an HHT has repeatedly been shown to be economically beneficial (Faculty for Homelessand Inclusion Health 2018 Luchenski et al 2017) by decreasing the length of inpatient stay andreducing re-admissions (Mathie 2012) Currently the RUH has no provision for referring ordischarging homeless patients

A successful HHT was piloted at the RUH in 2014ndash2015 to facilitate safe and effective dischargeof this patient group The team worked with 128 individuals over a 12 month period all thepatients worked with were given a single service offer and as such no one was discharged to NFAthrough lack of options (Wooton 2016) It was calculated that 899 bed spaces were saved duringthis time due to the commencing of discharge planning at admission Early and effectiveengagement saved the hospital pound224750 (Wooton 2016) The pilot scheme was well receivedby staff demonstrated good cost efficacy and improved health and wellbeing outcomesHowever it was discontinued due to the failure to secure ongoing funding

The discharge of NFA patients is a particularly pertinent issue as the Homelessness ReductionAct came into force in April 2018 which places a duty on public bodies including the NHS to referanyone threatened with homelessness to the local housing authority (UK Parliament 2017)

In summary there is overwhelming evidence in favour of introducing an HHT at the RUH Notonly is there an urgent need for this service but the positive outcomes of introducing an HHThave been demonstrated nationally and locally As well as the pressing public health andeconomic arguments as of April 2018 there is now also a legal imperative to take action


Research methodology

Given the need for an HHT to be established in the RUH the research agenda was to identifywhat components had proved successful to HHTs in facilitating the safe and effective dischargeof homeless patients As such a systematic literature review was undertaken as well as thereviews of successful case studies

Systematic literature review

The systematic review involved a comprehensive search across four databases EMBASEPubMed Google Scholar and Medline as well as recommended papers from the expert authorsSearch terms included homeless No fixed abode Homeless healthcare Team healthHospital Secondary care medic Discharge co-ordinate follow up Studies were limited tothose between 2008 and 2018 In total 84 relevant studies were identified 13 of which relatedspecifically to the research question

Case studies

Case studies of other successful HHTs across the UK Brighton (UHCW 2018) Gloucester(Barrow and Medcalf 2013) Bristol (BRI 2017) and London (Pathway 2014) helped to informthe model for the project in Bath Lessons were also taken from The Boston Healthcare for theHomeless Programme to take into account international best practice (OrsquoConnell et al 2010)

Research findings

From the literature review and case studies six elements of an effective HHT were identified

Jointly commissioned

Homeless Link evaluated 33 projects set up with funding from the governmentrsquos ldquoHomelessHospital Discharge Fundrdquo (Luchenski et al 2017) This evaluation clearly demonstrated thathaving a jointly commissioned HHT was key to securing funding and providing longevity to theproject (Luchenski et al 2017) It has also been demonstrated that having several differentbodies involved helps in steering the project and ensuring effective delivery (Luchenski et al2017 Mathie 2012)

Brighton HHT formed partnerships between primary and secondary care and third sector bodiesto secure adequate funding due to the scarcity of resource available for this vulnerable group(UHCW 2018) Collaborative working utilised the range of expertise available from each sector tofacilitate effective implementation and delivery

Key points

joint commissioning can overcome the scarcity of resource allowing long-lasting impact and

collaboration can appropriate different forms of expertise and improve communication between sectors

Individual care co-ordination within a multi-disciplinary team (MDT)

The medical model often focusses on a disease-centred approach to patient management Theliterature demonstrates that using an individual-centred approach represents a more accessibleway of engaging with homeless patients (Jego et al 2018)

Focussing on the individual and addressing their needs more holistically decreases the incidenceof self-discharge and improves engagement (Cornes et al 2018) Patients with complexpsychological physical and social care needs invariably require the input of a MDT Previousprojects have struggled to engage social services in taking responsibility for social care needs ofindividuals they support thus forging better working relationships with social work teams is anarea which needs particular attention (Homeless Link 2015)


Regular MDT meetings in all of the case studies examined facilitated direct communication andcollaboration between different specialties and enabled a holistic and individualised approach tocare The case studies supported the literature review findings that comprehensive long-termplans involving all specialities particularly social workers and caseworkers were the strongestpredictor of reducing re-admission rates and engaging the most complex patients (OrsquoConnellet al 2010 Pathway 2014)

Key points

individualised holistic care involving MDT input improves discharge outcomes and patientengagement and

social and case-worker input is of particular importance in finding long-term discharge solutions

Critical time intervention (CTI)

CTI is a model that supports the individual not just whilst in hospital but between discharge and beingsettled into community support services Having support in this period of time significantly improvesthe likelihood of individuals attending follow up or medical appointments (St Mungorsquos 2013) It alsoallows a full assessment of the individualrsquos needs once in the community and intensive supportimproves the sustainment of tenancy and health outcomes (Homeless Link 2015) Casemanagementis seen to decrease the burden of mental health symptoms and substance use (Luchenski et al2017) Having this support in place decreases the ldquorevolving doorrdquo of admissions (Mathie 2012)

The case studies that encompassed a system of high intensity community support immediatelyfollowing discharge were most successful in preventing frequent attenders from losingmotivation relapsing and being re-admitted to AampE This often involved assigning individuals withcaseworkers to take them to healthcare appointments help them with finances applying for jobsand accommodation (OrsquoConnell et al 2010)

Key points

ensuring a smooth transition from hospital to the community requires a period of intense communitysupport following discharge and

CTI improves long-term health outcomes and reduces frequent re-admissions to AampE

Patient involvement in decision making

Patient involvement is key to engagement and ensuring that services are acceptable and relevantto the individual (Luchenski et al 2017) The building of rapport with the patient is essential toengage and plan further housing and support needs a ldquoone size fits allrdquo approach is notappropriate (Mathie 2012)

The case studies demonstrated that placing patients at the centre of decision making sometimesposes challenges as patients are not always amenable to support Finding innovative solutions toconflicting priorities required creativity and building rapport with patients

Key points

Making progress often involves compromise and flexibility Respecting the patientrsquos priorities andbuilding rapport with the patient is an essential element of this

Sharing responsibility with the individuals is crucial to enable patients to take ownership of theirhealth in the longer term


Staff education

Hospitals have a notoriously high turnover of staff and thus education is quickly lost (Cornes et al2018) This is especially relevant in the AampE settings Providing regular education to staff to preventthis knowledge ldquoevaporatingrdquo is beneficial in improving attitudes and knowledge towards issues facedby homeless people (Cornes et al 2018) It has been suggested that a ldquohomeless championrdquowouldbe beneficial to ensure the ongoing delivery of appropriate care and support (Homeless Link 2015)

Boston Brighton and Gloucester established comprehensive teaching programmes to all staffand students This corresponded with a far more sophisticated understanding of the complexissues around homelessness health positive and proactive attitudes surrounding findingsustainable discharge solutions and understanding of the role and referral pathway of theirhospitalrsquos HHT (OrsquoConnell et al 2010 UHCW 2018 Barrow and Medcalf 2013)

Key points

positive staff attitudes and knowledge in respect of homeless healthcare is crucial to the successfulinitiation and maintenance of an HHT and

establishing a regular teaching programme was a strong predictor of continuing positive staffattitudes and knowledge

Housing and nursing staff within team ndash ideally with direct access to housing

There is a consistent evidence that involving nursing staff and housing workers within a teamleads to improved outcomes for homeless patients both in terms of decreasing the revolving doorof admissions and in getting people into suitable accommodation (Albanese et al 2016 Corneset al 2018) Integrating clinical staff into the team improved the health support received ondischarge by one-third but it also had a similar effect on those receiving housing support(Homeless Link 2015) It was unclear why this was the case but one explanation could be that itfrees up resources within the team Homeless people identify housing as the single mostimportant intervention necessary to improve their health and wellbeing and this finding is backedup by systematic reviews (Luchenski et al 2017) The evaluation of the Homeless HospitalDischarge Fund demonstrated that having accommodation linked to the project decreased re-admission by 10 per cent and increased discharge into suitable accommodation by one-thirdcompared to a housing officer alone (Homeless Link 2015)

Brighton Gloucester Bristol London and Boston all employed a dedicated housing officer withextensive knowledge of the local housing allocation system As council housing was often assignedbased on healthcare needs it would seem to follow that the incorporation of clinical staff in thedischarge process has the potential to help guide the housing officer through the housing applicationprocess Once patients were successfully housed their likelihood of re-admission fell substantially

Key points

the inclusion of an experienced housing officer and a nurse specialist within an HHT results in moresuccessful discharges and

securing stable housing is the most important factor in improving health and reducing re-admissions

Putting theory into practice the journey


The initial aim was to establish a joint commissioning structure whereby the HHT would bepartly funded through two of the three local Clinical Commissioning Groups (CCGs) namely


Wiltshire and BANES from whom the significant majority of NFA patients hailed18 In combinationwith an external funding source in this case St Johnrsquos Foundation Trust a ldquothink tankrdquo wasproposed by a senior clinician at the RUH in an effort to engage with and win the support of theCCGs A funding proposal was written by the Director of Julian House a local homelessnesscharity and then submitted to the St Johnrsquos Foundation Trust Disappointingly no more came ofeither of these avenues

In the course of further conversations with staff at the hospital it became apparent that therewas a sense of frustration and lack of hope that anything could be done to advance thehealth housing and social care needs of this particularly vulnerable patient group Peoplewere frustrated that the previous effort of establishing an HHT had come to naught and feltdiscouraged by this Especially as significant effort had been put into establishingand embedding it with the hospital There was also a lack of ownership insofar as no onewanted to take responsibility for the care of this patient group as everyone felt it was someoneelsersquos responsibility

To address these issues a ldquoprofile raising effortrdquo was instigated in order to raiseawareness of the lack of provision available to NFA patients at the hospital and to explorewhat if anything could be done to remedy this Following this a slot was obtained topresent at Grand Round ndash a weekly educational meetings for hospital staff to discuss casesand changing practice (Sandal et al 2013) ndash in an effort to engage with a broad range ofclinicians from across the hospital Dr Pippa Medcalf (Consultant Physician GloucesterRoyal Hospital) attended the seminar and presented evidence of how a successful HHTfunctioned at a similar local hospital Following the Grand Round the head of AampE wrote astatement of support detailing the need for such a service at the RUH This formed part of asubsequent external funding bid Further engagement with the Director of Medicine andDirector of Nursing generated additional ndash and much needed ndash clinical and managerialsupport for the proposal However identifying an appropriate source of funding remained amajor obstacle

As the project picked up momentum key contacts were established For example securing thesupport of Dr Medcalf opened the door to attending and presenting at the InternationalldquoSymposium for Homeless amp Inclusion Healthrdquo This in turn raised the profile of the project andfacilitated further networking opportunities with the London and Brighton and Sussex UniversityHospital HHTs whose subsequent input was invaluable for guidance in establishing the BathRUH project (eg job roles advice about funding bids etc)

Establishing connections with community partners was also vital Identifying and connecting witha key player in the community in this case the Director of Julian House Hostel led to furthercommunity connections being made which engendered significant third sector support Thesecommunity providers not only had extensive experience of homeless peoplersquos support needs butalso additionally had essential experience in grant writing and were aware of appropriate fundingpots to approach and access

Strong links were established with the Alcohol Liaison Team ndash a hospital in-reachservices run by the third sector charity Developing Health and Independence (DHI) DHIagreed to take the lead on writing a bid drawing on information and insights fromthe literature review and connections made with the Pathway team in Brighton The proposalfor a dedicated Homeless Health Team at the RUH was part of a larger bid submitted byDHI on behalf of the ldquoBath and North East Somerset Homelessness Partnershiprdquo ndash a networkof voluntary and statutory sector organisations which shares good practice and supporthomeless people into housing employment and good health (HomelessnessPartnership |Bathnes 2018)

During the background research a meeting had taken place with the Integrated DischargeService (IDS) Lead at the hospital This helped to identify that there was no provision for thedischarge of homeless patients and the difficulties social services experienced in regard to thisgroup IDS recognised that this was an unacceptable situation and was keen to find a solution tothis Once DHI had secured funding a meeting was arranged to facilitate communication andfoster working relationships between the DHI and IDS


Lessons learned

the importance of networking

raise the profile of the project within the hospital

find out what services are offered already within the hospital and how these are commissioned ndash egalcohol services ndash as such teams can often provide guidance and support

establish a rapport with social work teams early on particularly given the overlap and complexity ofhomeless patientsrsquo support needs

find out who the key players are in the community arrange to meet with these organisationsindividuals and find out their experiencewhat they feel is needed and

making links with hospitals where there is existing provision so as to learn from their experiencesand share resources

Individual care co-ordination within an MDT

In identifying suitable candidates for the role of housing officer particular attention was given toapplicants with direct experience of working with NFA individuals outside of the ldquohealthcaremodelrdquo and understood the importance of adopting a holistic approach to the role This wouldenable the team to focus on individual care co-ordination rather than deferring to clinicians and amedicalised perspective

The job description for the role of housing officer includes a mandate to raise the profile of theproject and thereby the healthcare needs of homeless patients within the hospital Additionally itrequires being proactive in the sense of searching out and making connections with auxiliaryteams within the hospital The housing officer is further empowered to take the lead incoordinating the MDT approach to patient discharge This involves ensuring that the patient isboth ldquosocially fitrdquo and ldquomedically fitrdquo for discharge It also involves managing ldquodiscordrdquo betweenthe two ndash eg by easing tensions between teams improving communication across the hospitaland actively advocating on the behalf of the patient

Whilst the HHT can co-ordinate individualised care with MDT input while the patient remains inhospital this model needs to extend into the primary care settings to ensure a smooth transitionto community services Preliminary meetings with members of primary secondary and socialcare services have taken place The longer-term aim is to establish regular MDT meetings acrossall three settings in the pursuit of supporting patients in transition from secondary to primaryhealthcare services and engagement with non-clinical support services in the community

Lessons learned

Candidates for a ldquohousing officerrdquo ideally come from a third sector background where they are moreaccustomed to an ldquoindividualrdquo approach to the patient rather than from the medical model

Include within the description of ldquohousing officersrdquo their role to act as a link between the disciplineswithin the hospital To do this they will need to have a ward presence and be proactive in learningabout what services are available within the hospital and motivated to seek these out and open adialogue with them

Critical time intervention

Initially the HHT will have capacity to provide CTI but as patient load increases the service willmost likely become overstretched Having an ldquoin-reachrdquo team as opposed to a hospital-specificteam could prove beneficial as ldquoThe Homelessness Partnershiprdquo has existing communityresources and links This makes it less likely that people get ldquolostrdquo to services when transferredfrom hospital to the wider community


The aim will be to assign the patient a key worker whilst an inpatient and ideally for that keyworker to meet together with the housing officer early in the discharge planning process If this isnot possible then the housing officer will meet with the patient and their key worker upondischarge to ensure a smooth transition

Lessons learned

Consideration needs to be given to the structure and delivery of CTI Having an ldquoin-reachrdquo service helpsovercome this issue Close collaborationwith the third sector is likely to be essential to the efficacy of CTI

Person-centred care and patient involvement in decision making

Appointment to the post was overseen by DHI Candidates for the position were asked to provideevidence of rapport building person-centred care and service user advocacy To determinewhether person-centred care and patient involvement in decision making is being met patientswill have the opportunity to provide feedback on how involved they felt in decisions about theirhealth and wellbeing and the support they received from the team to do this

Lessons learned

Listening to patients and improving practise based on feedback is essential to ensure optimal serviceprovision As such providing an anonymous feedback form to each patient the team works with is agood mechanism of determining this

The housing officer is crucial to the success or failure of the HHT Using an ldquoexpert by experiencerdquo inthe interview could be a useful tool

Staff education

A crucial element of the campaign to change staff attitudes about patients with NFAwas the provision of education on the general impact of homelessness on health and thespecific health needs of people who are homeless Teaching sessions were delivered acrossthe hospital to raise awareness of these needs and the importance of referral pathways andholistic forms of support

Part of the job specification for the housing officer is provide design and delivery educationthroughout the hospital They will be expected to proactively arrange regular teaching activitieswith clinicians and health and social care practitioners in key areas of the hospital (eg EDmedical admissions unit (MAU) etc)

Lessons learned

An education programme needs to be put in place in order to raise awareness of the function (andimportance) of an HHT Once an HHT has been established ongoing teaching on the referralpathway and the needs of NFA patients should be timetabled in an effort to mitigate the effects of therapid turnover of hospital staff


A huge advantage to the HHT being an in-reach service associated with DHI is the strongpartnership that already exists between the hospital DHI and local housing and homelessnessservices These relationships and resources have the potential to facilitate the timely placement ofpatients into temporary accommodation or intermediate care whilst a more permanentarrangement is sought


The successful bid allowed DHI to employ two ldquohousing officersrdquo to (re)establish the HHT withinthe RUH This will lay the foundation for the team however to have the greatest impact the HHTwill need to incorporate a healthcare element As such a second bid has been submitted torecruit a nurse to join the team in 2019

Lessons learned

an ldquoin-reachrdquo service can help provide strong links between the HHT and direct access tohousing and

the whole HHT does not need to be set up at once building-up the team on an incremental basis canbe a more achievable aim

Future aims

Joint commissioning ndash achieving statutory ldquobuy-inrdquo

Financial investment in the project from the hospital trust andor local CCGs is likely to bevital to the longevity of the HHT at the RUH This would provide a regular injectionof money that would allow for an advanced planning rather than a short-term planningSuch a commitment would serve to embed the HHT in the fabric of the RUH whilealso increasingly awareness and understanding of the homeless health agenda in thecommunity An example of this type of service model and funding arrangement alreadyexists within the RUH (ie the Alcohol Liaison Team is delivered by DHI and commissionedby the RUH)

Clearer referral pathway

Educating clinicians nursing and administration staff in AampE MAU and other ldquofirst contactrdquo pointswill be the first aim of the newly established HHT This will enable the early referral of NFA patientsto the team and thus allow discharge planning to commence at the point of admissionUltimately the aim is to establish an automated electronic system of referral to the team whichwould be ldquoset offrdquo during the clerking process This would streamline the service and minimise thenumber of patients slipping through the net It would also help to capture outcome data forauditing purposes

Closer collaboration with social care

The integrated discharge team (consisting of occupational therapists social workers fromthe three CCGs and allied health and social care professionals) have felt that NFA patientsdo not fall within their remit and have not been resourced to provide for this complex groupof patients

In the process of establishing the HHT communication between the HHT and the IDS has beenpromoted through a series of meetings between the IDS lead and DHI This has been positivelyreceived on both sides and there is scope and drive to work together closely It is envisaged thatthis collaboration will foster better relationship and understanding of the services each team canprovide and improve access to social services for NFA patients

Closer collaboration with primary care

Primary care underpins effective individualised care for vulnerable populations It providesa route into secondary care services that ensures appropriate admissions and use of hospitalservices an effective step-down service to avoid prolonging hospital stay and an effectivemeans of delivering preventative care thus preventing avoidable hospital admissions

Primary care has a critical role to play in providing medical follow up to the NFA populationCurrently Bath does not have an enhanced general practice for homeless patients It does


have is a sessional healthcare clinic based at Julian House Hostel The clinic runs threetimes a week and provides access to GPs and a specialist nurse practitioner Closecollaboration with this primary care team will be essential to ensuring that discharge planning is acoordinated process that prioritises the patientrsquos needs in the community As thingsstand the HHT is currently run as an in-reach service into secondary care from the thirdsector with little input from primary care This is not a sustainable model and as such relationshipswith primary care need to be forged The provision of a discharge summary and goodcommunication between the HHT and primary care will help foster closer collaboration betweensecondary and primary care The importance of having an HHT at the RUH is that it has thepotential to bring together and effectively co-ordinate the various elements of what makes for asafe discharge

Personal reflection

Rose My motivation for setting up an HHT in Bath arose from the experiences I had working inBoston and Brightonrsquos teams and a desire to apply the lessons I had learned there to the RUHSome of the most impressive aspects were the proactive collaboration across specialities and thesuccess in encouraging clients to access healthcare Despite the emotional challenges of the jobthe comradeship and mutual support among team members meant that the unit workedextremely effectively together I was inspired by the holistic patient-centred care that the teamsdelivered and the fact that this was clearly driven from genuine concern for the wellbeing of theindividuals they helped This compassion transformed patient attitudes from defensive anddisengaged to confident and motivated I was determined to try and emulate this approach inBath I am very fortunate to have found Katie who is passionate about the same cause It hasbeen a huge pleasure to work with her on this project and maintain collaboration with my formercolleagues in Brighton

Katie My motivation for this project arose from seeing numerous NFA patients at the RUH andbeing flummoxed by the difficulty in getting answers to what seemed like a simple question ofldquoWhere is this patient being discharged tordquo or ldquoWho is overseeing this patientrsquos dischargerdquoWhat began as initially ldquocuriousrdquo became consternating and I put more effort into finding ananswer When the answer was ldquothere is no provision for this patient grouprdquo it was something Icould not conscientiously ignore

Whilst I was on this journey I met Rose who heard me grilling one of the Alcohol Liaison Team sheimmediately spoke to me about her heart for this group of people and wanted to help in any wayshe could What is more Rose had considerable experience from working with the Boston andBrighton HHTs Thus began our friendship and project to at least try and find a solution tothis problem

With Rosersquos experience connections passion and networking skills combined with my tenacityneed for ldquoevidencerdquo and moderate organisational skills we combined to make a team whichcomplemented each otherrsquos strengths and encouraged one another to carry on when facedwith dead ends or rejections I was so blessed to have Rose onboard and would not have beenable to do it without her

The project taught me the importance of team working and how the skills and characterattributes others have can be immeasurable when facing a big challenge It also breaks up thephysical and emotional burden that a large project entails It also highlighted to me theimportance of networking there is a whole world of skills and services out there that is hiddenuntil you begin to meet and move in different circles I am constantly learning about theimportance of relationship in establishing a project a face-to-face meeting is so much morelikely to engender support and common purpose than simply an e-mail All of this may seemobvious but for me these things do not necessarily come naturally From my involvement in thisproject I have learnt and developed greater empathy with the NFA population which will haveongoing impact in my personal and clinical practise It highlighted to me how we still havevoiceless populations within our society and the need for those of us with a voice (howeversmall) to speak up for them


References

Albanese F Hurcombe R and Mathie H (2016) ldquoTowards an integrated approach to homeless hospitaldischargerdquo Journal of Integrated Care Vol 24 No 1 pp 4-14 doi 101108JICA-11-2015-0043

Aldridge RW Story A Hwang SW Nordentoft M Luchenski SA Hartwell G Tweed EJ Lewer DVittal Katikireddi S and Hayward AC (2017) ldquoMorbidity andmortality in homeless individuals prisoners sexworkers and individuals with substance use disorders in high-income countries a systematic review andmeta-analysisrdquo The Lancet Vol 391 No 10117 pp 241-50 doi 101016S0140-6736(17)31869-X

Barrow V and Medcalf P (2013) ldquoThe introduction of a homeless healthcare team has efficiently improvedpatient care and discharge outcome at Gloucestershire royal hospitalrdquo 2

BRI (2017) ldquoBristol Royal Infirmary homeless support teamrdquo available at wwwbristolgovukdocuments201820Bristol+Royal+Infirmary+Homeless+Support+Team+presentation33c13f6e-70cd-457c-aed0-e1abeda9697e

Cornes M Whiteford M Manthorpe J Neale J Byng R Hewett N Clark M Kilmister A Fuller JAldridge R and Tinelli M (2018) ldquoImproving hospital discharge arrangements for people who are homelessa realist synthesis of the intermediate care literaturerdquo Health and Social Care in the Community Vol 26 No 3pp e345-59 doi 101111hsc12474

Deloitte (2012) ldquoHealthcare for the homeless homelessness is bad for your healthrdquo pp 1-32available at wwwdeloittecomassetsDcom-UnitedKingdomLocalAssetsDocumentsResearchCentreforhealthsolutionsuk-research-healthcare-for-the-homelesspdf

Faculty for Homeless and Inclusion Health (2018) ldquoHomeless and Inclusion Health standards forcommissioners and service providersrdquo February available at wwwpathwayorgukwp-contentuploadsInclusion-Health-Standards-for-Commissioners-and-Service-Providerspdf

Fazel S Geddes JR and Kushel M (2014) ldquoThe health of homeless people in high-income countriesdescriptive epidemiology health consequences and clinical and policy recommendationsrdquo The LancetVol 384 No 9953 pp 1529-40 doi 101016S0140-6736(14)61132-6

Homeless Link (2015) ldquoEvaluation of the homeless hospital discharge fundrdquo January pp 1-55 available atwwwhomelessorguksitesdefaultfilessite-attachmentsEvaluation of the Homeless Hospital DischargeFund FINALpdf

Homelessness |Bathnes (2017) available at wwwbathnesgovukservicesyour-council-and-democracylocal-research-and-statisticswikihomelessness (accessed 16 September 2018)

Homelessness Partnership |Bathnes (2018) available at wwwbathnesgovukserviceshousinghousing-advicehomelessness-partnership (accessed 16 September 2018)

Jego M Julien A Diana-Elena S and Ceacuteline C-M (2018) ldquoImproving health care management in primarycare for homeless people a literature reviewrdquo International Journal of Environmental Research and PublicHealth Vol 15 No 2 p 309 doi 103390ijerph15020309

Luchenski S Maguire N Aldridge RW Hayward A Story A Perri P Withers J Clint S Fitzpatrick Sand Hewet N (2017) ldquoWhat works in inclusion health overview of effective interventions formarginalised and excluded populationsrdquo The Lancet Vol 391 No 10117 pp 266-80 doi 101016S0140-6736(17)31959-1

Mathie H (2012) ldquoImproving hospital admission and discharge for people who are homelessrdquo pp 1-44available at wwwhomelessorguksitesdefaultfilessite-attachmentsHOSPITAL_ADMISSION_AND_DISCHARGE_REPORTdocpdf

OrsquoConnell JJ Oppenheimer SC Judge CM and Taube RL (2010) ldquoThe Boston health care for thehomeless program a public health frameworkrdquo American Journal of Public Health Vol 100 No 8 pp 1400-8doi 102105AJPH2009173609

Office of the Chief Analyst (2010) ldquoHealthcare for single homeless peoplerdquo Department of Health March p 44

Pathway (2014) ldquoKings health partners pathway homeless teamrdquo pp 1-45 available at wwwpathwayorgukwp-contentuploads2015062014-first-year-report-KHP-Pathway-Homeless-Team-final-draftpdf

Royal College of Physicians (2013) ldquoFuture hospital caring for medical patientsrdquo Royal College of Physicians

Royal United Hospitals Bath (2014) Royal United Hospitals Bath NHS Foundation Trust Royal UnitedHospitals Bath NHS Foundation Trust available at wwwruhnhsukaboutindexaspmenu_id=1 (accessed7 August 2018)


Sandal S Iannuzzi MC and Knohl SJ (2013) ldquoCan we make grand rounds lsquograndrsquo againrdquo Journal ofGraduate Medical Education Vol 5 No 4 pp 560-3 doi 104300JGME-D-12-003551

St Mungorsquos (2013) ldquoHealth and homelessness understanding the costs and role of primary care services forhomeless peoplerdquo July St Mungorsquos pp 1-19 available at wwwmungosorgdocuments41534153pdf

Story A (2013) ldquoSlopes and cliffs in health inequalities comparative morbidity of housed and homelesspeoplerdquo The Lancet Vol 382 No S3 p S93 doi 101016S0140-6736(13)62518-0

UHCW (2018) ldquoAnnual report 2017-2018rdquo UHCW pp 1-241

UK Parliament (2017) ldquoHomelessness Reduction Act 2017rdquo Homeless Reduction Act 2017 C13 UKParliament p 19 available at wwwlegislationgovukukpga201713contentsenacted

Wooton R (2016) ldquoJulian house homeless hospital discharge annual report

XXXX (2018) ldquoRough sleeping ndash explore the data|Homeless Linkrdquo available at wwwhomelessorgukfactshomelessness-in-numbersrough-sleepingrough-sleeping-explore-data (accessed 16 September 2018)


Rose Isabella Glennerster can be contacted at roseglennersternhsnet



Improving outcomes for homelessinpatients in mental health

Zana Khan Sophie Koehne Philip Haine and Samantha Dorney-Smith

Abstract

Purpose ndash The purpose of this paper is to describe the delivery of the first clinically led inter-professionalPathway Homeless team in a mental health trust within the Kingrsquos Health Partners hospitals in South LondonThe Kings Health Partners Pathway Homeless teams have been operating since January 2014 at Guyrsquos andSt Thomasrsquo (GStT) and Kings College Hospital and expanded to the South London and Maudsley in 2015 asa charitable pilot now continuing with short-term fundingDesignmethodologyapproach ndash This paper outlines how the team delivered its key aim of improvinghealth and housing outcomes for inpatients It details the service development and integration within a mentalhealth trust incorporating the experience of its sister teams at Kings and GStT It goes on to show how theservice works across multiple hospital sites and is embedded within the Trustrsquos management structuresFindings ndash Innovations including the transitional arrangements for patientsrsquo post-discharge are described Inthe first three years of operation the team saw 237 patients Improved housing status was achieved in74 per cent of patients with reduced use of unscheduled care after discharge Early analysis suggests astatistically significant reduction in bed days and reduced use of unscheduled careOriginalityvalue ndash The paper suggests that this model serves as an example of person centredvalue-based health that is focused on improving care and outcomes for homeless inpatients in mental healthsettings with the potential to be rolled-out nationally to other mental health Trusts

Keywords Inclusion Health Homeless Pathway Mental Excluded


Introduction

Homeless and excluded groups experience extreme health inequity high morbidity andpremature mortality (Aldridge et al 2017) Mental illness in people experiencing homelessnessis common (Stergiopoulos et al 2017) and it is a key reason for attendance at emergencydepartments and admission to psychiatric wards (OrsquoNeill et al 2007) In England 80 per centof homeless people report some form of mental health issue and 45 per cent have beendiagnosed with a mental health problem with depression and severe mental illness likeschizophrenia being particularly pronounced (Homeless Link 2014 Aldridge et al 2017)Mental illness is thought to affect most people involved the homelessness drug treatment andcriminal justice systems (Bramley et al 2015 p 6) Welfare cuts proof of entitlement a localconnection (LC) (Dobie et al 2014) and the need for ID (Homeless Link 2017) areexacerbating pre-existing difficulties in accessing community support such as housing andhealthcare (Dobie et al 2014)

Homelessness is characterised by complex needs (Fazel et al 2014) described asldquotri-morbidityrdquo ndash the combination of physical illness mental illness and addictions (HomelessLink 2014 Stringfellow et al 2015) Yet uptake of preventative and scheduled healthcare byhomeless people is low (Luchenski et al 2017) Contacts with services are often ineffectivebecause the focus tends to be on addressing one problem as opposed to adopting an holisticapproach aimed at addressing complex health and social needs (Bauer et al 2013 SalizeWerner and Jacke 2013 Bramley et al 2015 Davies and Mary 2016)

Zana Khan is GP Clinical LeadKHP Pathway Homeless Teamat Lambeth Hospital ndash KHPPathway Homeless TeamLondon UKSophie Koehne is AdvancedMental Health Practitioner atLambeth Hospital ndash KHPPathway Homeless TeamLondon UKPhilip Haine is based at Guyrsquosand St Thomasrsquo NHSFoundation Trust ndash KHPPathway Homeless TeamLondon UKSamantha Dorney-Smith isNursing Fellow at LambethHospital ndash KHP PathwayHomeless Team London UK


Secondary care and homelessness

In the UK and Internationally health systems have identified the importance of integrated care forpeople experiencing homelessness with mental health needs (Fraino 2015 Stergiopoulos et al2017 Cornes et al 2018) Despite this increased awareness there remains a lack of dedicatedservice provision for people who are homeless in psychiatric inpatient and community mentalhealth settings (Bauer et al 2013) Moreover multi-disciplinary care planning reablementintegrated working and relationship building have been identified as important components insecondary care provision for homeless patients (Cornes et al 2018)

Pathway performed a randomised parallel arm-trial in two inner-city hospitals in order to comparestandard care (from a hospital-based clinical team) with enhanced care with input from specialisthomeless teams Although length of stay did not differ between the groups patients experiencingenhanced care recorded improved quality of life scores The group benefiting from enhancedcare was also found to be less likely to be discharged on to the street following a period ofhospitalisation (Hewett et al 2016) To date this service delivery model has not been replicatedin a mental health setting in the UK Internationally however intensive inpatient psychiatricsupport for homeless people has been shown to improve engagement reduce relapse(Killaspy et al 2004 Pearson 2010) and improve tenancy sustainment The deployment ofmulti-disciplinary care has been found to be effective in improving residential stability andreducing admissions to psychiatric hospitals (Stergiopoulos et al 2015)

Method

This paper reviews existing literature to understand how the role of specialist inpatient homelessteams has become established in secondary care settings It also draws on the personalexperiences and observations of the team working in a specialist in-reach homeless hospitalteam in a mental health setting at the South London and Maudsley (SLaM) Foundation Trust inSouth London This approach is complemented by the inclusion of routine clinical anddemographic data (eg each episode of care and includes demographics at admissioninterventions and outcomes at discharge) collected by the Pathway team at SLaM and earlyfindings from the evaluation

The Pathway approach to multi-disciplinary care for homeless in patients

In 2009 the Pathway Charity implemented a model of GP and nurse-led homeless hospital wardrounds at University College Hospital London based on a similar service run by consultantsBoston USA (wwwbhchporg) Key tasks include reviewing clinical and discharge goalsassisting with care planning explaining medical findings communicating with multiplehospital-based teams and community service providers so as to facilitate a safe discharge(Hewett et al 2012) The Pathway model has since grown and spread across acute care settingsin the UK and internationally to Perth Western Australia As noted earlier however the Pathwayapproach has not as yet been applied in a mental health setting (wwwpathwayorgukteams)

Following an urban multicentred needs assessment in South East London (Hewett andDorney-Smith 2013) the Kings Health Partners (KHP) Pathway Homeless Team servicecommenced at Guyrsquos and St Thomasrsquo (GStT) and Kings College Hospital (KCH) in January 2014The service was expanded to SLaM in February 2015 The service aims to improve health andhousing outcomes for homeless people admitted to hospital improve quality of care and reducedelayed or premature discharges from hospital (Dorney-Smith et al 2016) The needs assessmentsought to establish the cost of attendances and admissions while also actively involving patients andstakeholders in shaping solutions It demonstrated that homeless psychiatric admissions cost almostpound27m annually across four boroughs (Hewett and Dorney-Smith 2013) Additionally a study atSLaM identified the need for housing was a cause for delayed discharged and that homelessnesswas independently associated with a 45 per cent increase in length of stay (Tulloch et al 2012)

Lambeth and Southwark Clinical Commissioning Groups (CCGs) funded the KHP PathwayTeams at GStT and KCH from 2014 whilst the team at SLaM was funded by the GStT and


Maudsley (SLaM) charities as part of a three-year pilot The inter-professional team includes GPsgeneral nurses mental health practitioners (MHP) occupational therapists and a social workeremployed by the hospital trusts The housing workers and peer advocate are seconded from thevoluntary sector (St Mungos St Giles Trust the Passage and Groundswell) The SLaM team iscomprised of two full-time Band seven MHP a sessional GP a housing worker from one of thepartner voluntary organisations three days a week and a business manager one day a weekThe team is overseen by an operational manager and has senior clinical management from aclinical director The service evaluation is supported by clinical academics from the Institute ofPsychiatry and Kings College London The teams work together to improve outcomes andexperience of homeless and vulnerably housed people across the three hospital trusts

Service attributes

Overview

The SLaM NHS Foundation Trust is a large secondary mental healthcare provider withresponsibility for secondary mental healthcare support to four South London boroughs (CroydonLambeth Lewisham and Southwark) along with tertiary mental health services to a widerpopulation There are four hospital sites providing inpatient provision for each borough and somenational services The catchment population served by the Trust is over 2m people mostlyresident in inner-city areas

The aims of the service are to improve health and housing outcomes for homeless people admittedto hospital improve quality of care while reducing delayed or premature discharges from hospitalThe key outcomes are to reduce unscheduled admissions and support access to scheduled careand community services The team provides expert review and support around housing and healthissues by assertively advocating for patients through partnerships and links with GPs communityhealth services social services housing departments hostels outreach teams and a wide range ofcommunity and voluntary sector services Within the trust the team works closely with bedmanagement ward managers and the welfare team The team developed a forum with otherhomeless services at the Trust including Psychology in Hostels and the START team (a roughsleepersrsquo mental health outreach service) and works collaboratively with the Health Inclusion Teamndash a community nurse-led homeless service based in Lambeth Southwark and Lewisham

Service development

The needs assessment in 2012 estimated that there are around 150 admissions of homelesspeople a year across all four SLaM sites To effectively plan the service design and delivery theteam were appointed before the service launch They undertook a simple survey of SLaM wardsand found that across the 12 responses 22 per cent of patients (nfrac14 46) patients were assessed ashaving had an episode of homelessness that month and in 13 per cent cases this was perceived tobe a current cause of delayed discharge In the previous five months the place of safety (emergencypsychiatric ward) identified 84 patients without a LC to the hospitalrsquos four boroughs Staff identifiedchaotic lifestyles and lack of suitable placements as key to discharge delays

This snapshot identified more patients than the needs assessment Due to limited resourcesit was agreed that the team would see patients admitted to Lambeth and Southwark psychiatricwards (Lambeth Hospital and Maudsley Hospital) who were not in contact with a CommunityMental Health Team (CMHT) In practice patients have been seen with and without a LC to allfour SLaM boroughs (Southwark 25 per cent Lambeth 24 per cent Lewisham 9 per cent andCroydon 7 per cent) Patients linked to CMHTs are supported with advice and signposting Theteam had the benefit of the experience of the Pathway Teams at GStT and Kings before goinglive so were able to make the decision to incorporate a housing worker into the service toaddress some of the issues raised in the audit Going forward NHS funding has been identified tosupport a whole-time housing worker This will enable the team to work in partnership withinpatients linked to a CMHT It is perhaps worth noting here that the team have come toattribute the underestimation of homeless admissions to the fact that patients are typicallyadmitted to SLaM primarily based on GP registration which is usually linked to a historic address


Routine data collection would consider these patients as housed This is an important learningpoint for other Mental Health Trusts considering a Pathway Homeless Team

KHP pathway homeless team at SLaM receives referrals for admitted patients in Lambeth andSouthwark who are homeless or vulnerably housed and without a care co-ordinator This isirrespective of their right to statutory entitlements nationality or LC

Referral criteria

admitted to a SLaM inpatient ward

18+

patients living in homeless hostels BampB sofa surfers or who have nowhere to go ondischarge

patients with any mental health diagnosis

patients without a care co-ordinator including those with no local housing connection and norecourse to public funds (NRPF) and

homeless frequent attenders eg to AampE acute wards or place of safety andor patients whoare having both physical health and mental health admissions

The team accepts referrals for patients who meet the criteria but will offer advice to careco-ordinators or wards for patients who do not

Having a care co-ordinator linked to a CMHT was the main reason why patients were notaccepted to the caseload The team reviews patientsrsquo notes and offers advice information andsignposting to support care-coordinators Patients referred from wards outside of Lambeth andSouthwark were offered the same advice service

Service model

At referral the team reviews the hospital records and routinely checks several databasesincluding

NHS Spine ndash to see if clients are registered with a GP and to review housing historyassociated with GP registration Next of kin details are also sometimes available

CHAIN ndash rough sleepersrsquo database for London which includes details of sleep sites keyworkers and service contacts

EMIS Web ndash a primary care record system also used by the Health Inclusion Team and whichis now used by other Pathway Teams and healthcare providers across London with workalmost complete to develop data sharing

Local care record ndash records test results and documents from local hospitals and practices insome areas It can help confirm medical history and medication

The team works closely with a wide variety of services across the Trust and in the widercommunity An audit of patients found that on the average the team liaised with five services perpatient though for very complex patients the figure was substantially higher at 11 servicesCommunication and case planning therefore underpin the work of the team and on average theteam attends six multi-disciplinary ward round meetings a week

In 2015 the KHP teams successfully applied for charitable funding for a three-year specialist legaladvice project The funding enabled Southwark Law Centre to provide rapid advice by e-mail orphone in housing immigration and welfare law The law centre attends a clinical meeting at eachsite once a quarter in order to provide updates on relevant case law and statute specificallyrelating to housing welfare and immigration This service has proved to be an invaluable resourceto the KHP team primarily as a means for furthering legal knowledge and understanding but alsoimportantly for individual patients who have benefited from access to legal advice The LawCentre has also taken on specific cases (Figure 1)


Specialist team roles

The Pathway model allows the team to use both their specialist expertise and more generic skillsHolistic assessments are undertaken by any member of the team and reviewed as part of a dailyteam meeting Cases are discussed weekly between the whole team at the case review meetingDepending on the specific circumstances a plan will be outlined and communicatedwith the patientand the ward For example patients who are rough sleeping before admission may besupported to make homelessness or supported accommodation application whereas thosewho are at risk of eviction would need support from the local authority to maintaintheir accommodation or be housed somewhere more suitable Referrals are made for Care Actassessments where patients have care needs or require mental health supportedaccommodation Those without entitlement to statutory services will be supported to accessprivate rental accommodation night shelters or legal support

All patients are supported to register with a GP and apply for welfare benefits (if eligible) Appropriatefollow up is arranged before discharge Patients are also supported to access necessities such as amobile phone foodbank vouchers and subsistence until benefits are established

Teammembers have had training to develop in specialist expertise in NRPF Mental Capacity ActMental Health Act safeguarding welfare benefits modern day slavery and trafficking along withkey clinical content such as substance misuse (see Figure 2)

Mental health practitioner (MHP)

The MHPs have experience of working with a wide variety of mental health conditionsthus providing the team with valuable knowledge and insight into the needs of peopleexperiencing mental health problems The MHPs jointly run the service which ensurescontinuity of care from inpatient to community services They screen all referrals andallocate cases to the appropriate team member Part of the assessment process involvesassessing patientsrsquo health and social care needs communicate plans and makingrecommendations to the admitting teams They also take the lead on working with wardstaff to plan for safe discharge This process includes formulating care plans and riskassessments around the functional impact of homelessness and advocating around impact ofmental health on homelessness The MHPs independently contribute to supporting medicalletters and reports around homeless and health issues They also provide mental healthsupport and advocacy for patients at housing appointments when required communicatingthe risks and needs of complex clients with other services MHPs also lead on delivering trainingto wards and other professional groups offer student placements and present at externalconferences and events

Figure 1 Internal and external services the team works with

WardsReablement Team

(Southwark)START Team

Southwark LawCentre

Bed managementmeetings

Local authorityHousing

Departments

St Mungos ThePassage St Giles

GP surgeriesStreet Outreach

teamsHostels Place of Safety

Non-localauthority housing

providersCMHTs

Health InclusionTeam (HIT)

No RecourseTeams

Hospital SocialWork teams

(Lambeth andLewisham)

KHP Teams atKings and GSTT

Routes Home Night Shelters

Home OfficeImmigration

servicesEmbassies

Welfare teamsndashfor benefits advice

and support

Department ofWork andPensions

PolicendashProbation OT department SolicitorsHomeless Day

centresHIV Liaison Team

Other MentalHealth Trusts

Wellbeing HubsSolidarity in a

CrisisInterpreterservices

Food banks

Notes Internal SLaM services are green and external services are blue


Housing worker

The housing worker role is a rotational post across all KHP teams It provides an opportunity forthe housing worker to develop expertise through working in different healthcare settings and withpatients with differing primary health needs The housing worker is experienced in providinghousing advice and advocacy using knowledge of housing law and regulation to identify allpossible housing options They will support clients to make homeless presentations to thecouncil present evidence collected by the team and advocate in respect of homelessnesslegislation The housing worker is also able to provide rapid housing advice and signposting whenpatients have a brief admission

GP

This is the first time a GP has been employed in a senior (consultant grade) role within SLaMPatients with severe and enduring mental illness are at a significantly increased risk of developingphysical health problems in part this is attributable to the medication a patient might receiveThe GP supports patients to be screened and treated for health problems before handing over tocommunity teams at the point of discharge The GP works closely with consultants to understandthe role of the team and to promote shared working The GP is also responsible for writing clinicalletters of support for patients both for statutory homelessness applications and for supportedaccommodation routes and writes GP to GP discharge summaries to improve handover of patientcare and follow up needs The GP has coordinated the service evaluation and communicatesfindings and outputs to the operational management and steering committees within the trust andoutwardly through Pathway and at local and national meetings and conferences

Business manager

The business manager supports the team with collecting recording and analysing data andproducing quarterly reports The business manager oversees payments and liaison with thepartner organisations and maintains overall administration and management support

Clinical academics

During the pilot phase the charity grants included funding for a research evaluation incollaboration with a clinical academic and a health economist This included a data analysis andan economic analysis Following pilot funding the team received short-term CCG funding

Figure 2 Interventions of the KHP Pathway Homeless team

Holistic NeedsAssessment

andRisk Assessment

Liaison withServices

Reconnection

Housingsupport

Communityhealth follow

up

Practicalassistance

GP review andliaison

FrequentAttender

Work

Challengingpractice

CommunityAccess

Advocacy

Informationgathering

Identifyingldquomissingrdquopersons

Sta

ff Tr

aini

ng

Care C

oordinator Advice


Outcomes and patient demographics

The pilot service ran from December 2014 to December 2017 and received 465 referrals of which237 met the teamrsquos criteria

Data analysis showed that 34 per cent were admitted voluntarily 27 per cent under section 2 and14 per cent under section 3 of the Mental Health Act Severe mental illness was diagnosedin 77 per cent of patients seen (psychosis 54 per cent schizophrenia 12 per cent and bi-polar11 per cent) Emotionally unstable personality disorder was reported or diagnosed in 19 per centof patients Tri-morbidity was evidenced with a quarter of patients reporting a past medicalhistory A total of 24 per cent reported harmful or problematic drinking 17 per cent reportedalcohol dependence and 13 per cent drug dependence Also suicidality or self-harm affected38 per cent of the patients In total 5 per cent of patients seen were HIV positive and 2 per centHepatitis C positive which is considerably higher than the local prevalence Chronic illnesses(diabetes asthma COPD and Epilepsy) affect 14 per cent of patients Of note a quarter ofpatients had a history of violent behaviour towards others (Table I)

A total of 175 patients (74 per cent) seen by the service had an improved housing statuson discharge Patients were support to access emergency (eg night shelters) and supported(eg hostels) accommodation private rental properties while others were successfully reconnectedA further 25 (11 per cent) had their housing status maintained largely by preventing loss ofaccommodation It is not possible for the team to improve housing status in all instances indeedsome patients will return to rough sleeping or self-discharge or abscond from the ward A total of57 patients (24 per cent) presented to housing departments and 67 patients (28 per cent) werereferred for supported accommodation Where housing solutions were not found patients receivedadvice signposting and case work to identify key workers and services that could support themIn total 133 patients (56 per cent) were seen by a housing worker and 95 letters were written by theGP to support housing applications The average length of stay was 33 days

These outcomes include the 24 per cent of patients who had NRPF The team saw an increase inreported rough sleeping from 24 per cent of patients seen in the first year to 48 per cent seen inthe second year This is likely to reflect the on-going increase in rough sleeping in England(Ministry of Housing Communities and Local Government 2017)

Reconnection

Reconnection in the context of the teamrsquos work is defined as outside of SLaMs four boroughsLC is established by taking a patientrsquos housing history and identifying their eligibility for housingfunded by the local authority

There are several reasons why it is important to accurately identify LC and thus avoid submittinghomelessness applications to arbitrarily selected local authorities (LA)

1 The team has developed positive relationships with the nearest LA and depend on them forassistance for a large proportion of the caseload Additionally many people experiencinghomelessness come to London from elsewhere

Table I Housing status at admission of patients referred to the service

Housing status Number Percentage

Rough sleepers 85 359Sofa surfing 54 228Living with family 29 122Private rental accommodation 26 11Living in a homeless hostel 9 38Housed 5 21Temporary accommodation 6 25Other (night shelter squats) 7 29Unknown (discharged or transferred before assessment) 16 68


2 Certain services are provided on a discretionary basis which means that LA have no legalduty to provide them Therefore hostel and supported housing pathways usually only acceptpeople with a very clear LC

3 LA have a ldquopowerrdquo to refer to another local authority for discharge of full duty (permanent offerof accommodation) once the patient has received a positive decision for permanent housingIt is more sensible to approach the local authority where the client is likely to receive this full dutyfor housing and offer a supported transition from hospital than a potentially unsupported one

It is worth acknowledging that individually patients have a right to approach any local authoritythey want in an emergency In such emergencies the Pathway Homeless Team may not be ableto identify a LC so may consider approaching the nearest local authority for assistance Similarlywhere patients are fleeing violence we are more likely to support the patientrsquos choice even if thereis no documentary evidence of violence (although the team endeavour to help them obtain suchevidence wherever possible)

A total of 157 patients (66 per cent) seen by the team had a LC to one of the SLaMrsquos fourboroughs Given that admission is based on registration with a local GP patients are usuallyadmitted either because they are NFA (with no GP) or due to historic GP registrationThis indicates a high level of transience as well as the importance of identifying patients whocan be reconnected outside of the SLaM boroughs where they may have an entitlement toaccess housing

Reconnection is a challenging work and involves the whole team from the point of identifying thepatientrsquos most likely borough of LC through to working with the patient to make applications tohousing departments and support services and registering patients with a local GP Due to theneed for a local GP and address it can be challenging to organise CMHT follow up outside ofSLaM boroughs but the team achieves this by arranging GP registration and working withadmitting teams to ensure follow up is arranged before discharge A total of 61 (30 per cent)patients were offered reconnection outside Local and London Boroughs and 12 per cent ofpatients have a LC outside the UK In total 50 (21 per cent) were successfully reconnectedThose who declined reconnection are supported to access services such as night sheltersprivate rental accommodation or to stay with friends and family members This underscores thefact that reconnection is an important activity for the team

Evaluation findings

Statistical analysis

Dr Alex Tulloch worked closely with the team to develop a ldquologic modelrdquo which links the operationof a service to activities outputs and outcomes It showed that the Pathway intervention shouldimpact bed days readmission to hospital and use of services after discharge SLaM benefits fromcomputerised anonymised data on all admissions allowing identification of a homeless controlgroup who did not receive Pathway input Mathematical modelling provided comparison of beddays and rate of readmission Early analysis shows that the intervention reduced bed days butnot readmission rates

Service use inventory

Professor Paul McCrone worked closely with the team to develop an acceptable version of ClientService Receipt Inventory to measure acute and community service use at admission 3 and 6mintervals Unit costs of services were then attached

Early analysis shows that unscheduled care was reduced and community mental health wasincreased in the intervention group

Cost savings

Early analysis shows that patients experiencing the Pathway intervention receive better care andoutcomes at no additional cost and possibly a reduced cost to the NHS


Operational development

Working with local authorities and voluntary sector

It is important to note that LA are experiencing increasing homelessness applications against thebackdrop of funding cuts and a chronic shortage of affordable social housing The team hastherefore sought to enhance its relationship with housing teams and housing provision throughworking collaboratively with LA and the voluntary sector This is exampled by

raising awareness of the impact and vulnerability of patients experiencing the full spectrum ofmental health problems including suicidality depression anxiety and personality disorder inaddition to psychosis

raising awareness of the needs and risks of young people with mental health problemsparticularly in the context of family and relationship breakdown

working with colleagues from the Southwark Law Centre to clarify the responsibilities andinteraction between the Care Act LC and section 117 aftercare of the Mental Health Act

referring to and collaborating with voluntary sector housing services

highlighting the overlap and inter-relationships between physical health mental health andsubstance misuse problems and

developing hospital discharge protocols with local boroughs

Patient and staff feedback

Each year the KHP Teams undertake a cross site series of structured interviews with patientsfrom all three teams Patients described how the Homeless Team had kept them fully informedabout their care and had maintained good communication with between ward staff and otheragencies involved Most patients rated the KHP Pathway Teams as good or excellent

Direct feedback from patients seen by the Pathway Homeless Team at SLaM

[hellip] inspired by your kindness I am this Christmas holiday volunteering with Crisis (Patient)

I feel happy inside and Irsquove never felt like that before (Patient)

Integration within the trust

As the team became firmly embedded within the Trust it quickly became clear that ward andcommunity teams needed support in managing the onward care and discharge planning ofhomeless patients They articulated the challenge in managing homeless patients so were ableto see the impact of teamrsquos expertise and skills and a change in approach away from dischargingto the streets Consultants described meaningful and positive outcomes for homeless patientswithin rapid timeframes The team facilitates care through regular communication both within theteam and by regularly reviewing patients on wards and in wards rounds Stigma and poordischarges were challenged directly with those involved Direct feedback from staff articulated theadded value of the service and improved care and outcomes for patients

Irsquove noticed a real change in the culture towards homelessness most notably in the ending of thepractice of discharging to the street (Nurse on acute psychiatric ward)

Through successfully tackling the complex issues [hellip] I have absolutely no doubt that this Team havepaid for themselves many times over (Consultant Psychiatrist)

Case 1 role of the GP and reconnection

Patient 35-year-old female from an EEA country arrived in the UK following relationshipbreakdown previously living with family in home country

Medical problems relapse of Bi-Polar affective disorder after lapsing from treatment diagnosedwith type 2 diabetes following routine blood screening on ward

Other problems not entitled to statutory service in UK children and family support in homecountry admitted to SLaM because she was using a local address


Activities initiated by the Pathway Homeless Team she was assessed by a MHP and supportedto consider options lack of entitlements in UK and away family support MHP liaised with thefamily and supported the ward to do the same

Activities initiated by the GP the GP noted that tests results and requested repeat blood tests toconfirm the diagnosis GP met the patient on several occasions and provided advice and leafletsGP discussed the case with the diabetes team and agreed to manage the patient on the wardwith oral medication GP supported the patient to start treatment

Overall achievement patientrsquos mental health improved and she received a supportedrepatriation re-engagement with her family and follow up arranged with local specialist teams

Case 2 role of the MHP and housing worker in dual diagnosis

Patient 34-year-old woman history of dual diagnosis and Post Traumatic Stress DisorderAdmitted with a paracetamol overdose and self-harm She was not referred to the HomelessTeam as she gave a historic address but was recognised by the Pathway team housing workerwho saw her during a recent admission to Kings

Medical history crack addiction and recently terminated pregnancy

Other problems sex working vulnerable and homeless for several years residing in crackhouses and fled temporary accommodation History of childhood trauma and domestic violenceas an adult children living with their father who raised safeguarding concerns Patient wanted togo to rehab

Activities initiated by the Pathway Team a safeguarding alert was raised by MHP The housingworker secured temporary accommodation through the local authority and follow up wasarranged with the substance misuse and mental health teams A multiagency safeguardingmeeting was organised by MHP and a referral to rehab KHP Pathway Teams were aware of thecase and the plan if the patient presented

Following a period of loss of contact with services and further admissions the patient was placedin an all-female rehab outside of London She remained there for four months and contacted herchildrenrsquos father until she left the rehab and lost contact with services again

The patient maintained phone contact with the MHP and through this she was accepted at alocal hostel Over time her care was handed over to the Health Inclusion Team nurse and thehostel staff who supported her to register with a GP engage with substance misuse servicesand specialist services for sex workers

Overall achievement patient has been in the hostel for 18 months She has attended AampE twicebut was not admitted She is engaging with health services and although she remains sexworking and using drugs she has maintained accommodation which has reduced the risks toher safety

Community mental health follow up

The period around discharge from hospital has been recognised as higher risk due totransitioning between accommodation and services (Windfuhr and Kapur 2011) Best practiceguidance recommends a community follow up within a week of discharge (NICE 2016) Fromearly in the service it became clear that lack of address was a barrier to linking patients withCMHTs for ldquoseven daysrdquo or other community follow up particularly in a first or new presentation

Once LC is confirmed the team ensure that patients have as many aspects of follow up in placebefore discharge from the service Once this is recognised the team will work closely with wardsand CMHTs to develop closer working relationship enabling appointments referrals and careco-ordinators to be allocated before discharge or as soon afterwards if this is not possible

Transitional support

The team identified a need to work with some patients for a period post-discharge to support asmoother transition into their new accommodation status The team recognised that transition


from hospital to unfamiliar accommodation is challenging and that this can both cause anxietyand increase the risk of accommodation breakdown and return to homelessness Transitionalsupport needs include

supporting someone to maintain their accommodation

setting up benefits payments

supporting on-going housing applications and

engagement in meaningful activity or support to engage with new CMHTs

Transitional support is planned with the patient at the time of discharge from hospital dependingon patient need other community support already in place location of new accommodation andtype of accommodation ndash eg temporary unsupported or BampB Support may be over the phoneor face-to-face depending on patient need and team resources On average the team works withpatients for ten days post-discharge Patients are discharged from the caseload oncelonger-term support is in place or there is no longer a need for the support This work is similar toa ldquocritical time interventionrdquo model which could be tried more formally in mental health settings(de Vet et al 2017)

Meaningful activity after discharge

Prior to or at the time of discharge the team will provide information and signposting to patientsto orientate them to the local area and available services ndash eg public libraries community mentalhealth services returning to work volunteering and peer support

Discussion

Previous evidence supports the role and value of specialist homeless health teamsin secondary care in improving health and housing outcomes in homeless inpatients(Dorney-Smith et al 2016 Hewett et al 2016 Blackburn et al 2017) The KHP PathwayHomeless Team at SLaM supports the role of these services in mental health trusts andconfirms that they offer effective person-centred care While there is frequently a desire to focuson the economic benefits of new models of care the work of the Pathway HomelessTeam is underpinned by values of equity social justice and parity of care for homeless andexcluded groups

In previous service evaluations there was an immediate but ultimately unsustainable reductionin bed days probably due to rapid resolution of less complex cases (Dorney-Smith et al 2016)and this was in the absence of a statistical evaluation of the service The robustresearch evaluation at SLaM demonstrates improved housing status and altered use ofhealthcare services after discharge with a statistically significant reduction in bed days Theanalysis accounts for the variation in complexity and other confounding factors that limitprevious evidence

The benefits of consistent positive outcomes for patients are reflected in positive relationshipswithin the Hospital Trust This resulted in earlier identification of homelessness issues andreferral to the service with an improved understanding of the importance of safe and effectivedischarge arrangements for complex patients This is particularly relevant given the increasingnumbers of rough sleepers in England (Ministry of Housing Communities and LocalGovernment 2017)

This paper is limited by the service model and evaluation components By way of illustration ittook a full year to establish the remit of the evaluation and programme of work The evaluation didconsider measuring health-related quality of life but limited time of the clinical academics andlimited academic experience of the GP to complete the evaluation resulted in a narrower focus onbed days and service use This focus was privileged on the basis that it was more likely to lead toon-going NHS funding However it is vitally important for organisations who want to implementinpatient homeless teams to learn lessons from this team As such Pathway homeless teams arecomplex service interventions So we would argue that applying flexible use of the MRC


framework for complex interventions can offer a more structured and a theoretically-informedapproach to developing the service and associated evaluation (Craig et al 2008)

Future research in this area should include qualitative interviews with patients and staff exploring thebarriers and facilitators to caring effectively for homeless and excluded groups Interviewswith patientsand an assessment of long-term outcomes and quality of life measures would also be valuable

In April 2018 the Homelessness Reduction Act came into effect in England and from October2018 Public Bodies including NHS Trusts will have a duty to refer anyone who is homeless or atrisk of homelessness The impact of this on NHS Trusts remains to be seen though there isreason to believe that NHS Trusts with a Pathway Homeless Team are likely to be particularly wellplaced to respond to this agenda

The use of evidence to support service development and delivery is essential Clinical teamsworking with researchers in leading the design and delivery of services seems to be a robustmodel for quality and efficiency in healthcare Whilst the NHS continues to experience financialchallenges these constraints should not affect the implementation of best practice andvalue-based healthcare (Porter 2010) nor should it stand in the way of improving health of thepoorest fastest (Marmot and Bell 2012) Providing person-centred care which enablesindividuals to address their health social and housing needs together gives the patient the bestopportunity to break the cycle of homeless

References

Aldridge RW Story A Hwang SW Nordentoft M Luchenski SA Hartwell G Tweed EJ Lewer DVittal K Srinivasa H and Andrew C (2017) ldquoMorbidity and mortality in homeless individuals prisoners sexworkers and individuals with substance use disorders in high-income countries a systematic review andmeta-analysisrdquo The Lancet Vol 391 No 10117 pp 241-50

Bauer LK Baggett TP Stern TA OrsquoConnell JJ and Shtasel D (2013) ldquoCaring for homeless personswith serious mental illness in general hospitalsrdquo Psychosomatics Vol 54 No 1 pp 14-21

Blackburn RM Hayward A Cornes M McKee M Lewer D Whiteford M Menezes D Luchenski SStory A Denaxas S Tinelli M Wurie FB Byng R Clark MC Fuller J Gabbay M Hewett NKilmister A Manthorpe J Neale J and Aldridge RW (2017) ldquoOutcomes of specialist dischargecoordination and intermediate care schemes for patients who are homeless analysis protocol for apopulation-based historical cohortrdquo BMJ Open Vol 7 No 12


Cornes M Whiteford M Manthorpe J Neale J Byng R Hewett N Clark M Kilmister A Fuller JAldridge R and Tinelli M (2018) ldquoImproving hospital discharge arrangements for people who are homelessa realist synthesis of the intermediate care literaturerdquo Health and Social Care in the Community Vol 26 No 3pp e345-59

Craig P Dieppe P Macintyre S Michie S Nazareth I and Petticrew M (2008) ldquoDeveloping andevaluating complex interventions the new medical research council guidancerdquo BMJ Vol 337

Davies J and Mary L (2016) ldquoInclusion health education and training for health professionalsrdquo available atwwwgovukgovernmentuploadssystemuploadsattachment_datafile490870NIHB_-_Inclusion_Health_education__Reportpdf (accessed 24 July 2018)

de Vet R Beijersbergen MD Jonker IE Lako DAM van Hemert AM Herman DB and Wolf JRLM(2017) ldquoCritical time intervention for homeless people making the transition to community living a randomizedcontrolled trialrdquo American Journal of Community Psychology Vol 60 Nos 1-2 pp 175-86

Dobie S Sanders B and Teixeira L (2014) ldquoTurned awayrdquo available at wwwcrisisorgukmedia20496turned_away2014pdf (accessed 24 July 2018)




Fraino JA (2015) ldquoMobile nurse practitioner a pilot program to address service gaps experiencedby homeless individualsrdquo Journal of Psychosocial Nursing and Mental Health Services Vol 53 No 7pp 38-43

Hewett N and Dorney-Smith S (2013) ldquoKingrsquos health partners and the impact of homelessnesswith proposed responsesrdquo available at wwwpathwayorgukpublicationspathway-research-and-service-development-publicationskings-health-partners-and-the-impact-of-homelessness-with-proposed-responses (accessed 24 July 2018)

Hewett N Halligan A and Boyce T (2012) ldquoA general practitioner and nurse led approach to improvinghospital care for homeless peoplerdquoBMJ [Internet] Vol 345 p e5999 available at wwwbmjcomcgidoi101136bmje5999

Hewett N Buchman P Musariri J Sargeant C Johnson P Abeysekera K Grant L Oliver EAEleftheriades C McCormick B Halligan A Marlin N Kerry S and Foster GR (2016) ldquoRandomisedcontrolled trial of GP-led in-hospital management of homeless people (lsquoPathwayrsquo)rdquo Clinical Medicine Journalof the Royal College of Physicians of London Vol 16 No 3 pp 223-9

Homeless Link (2014) ldquoThe unhealthy state of homelessness health audit resultsrdquo available at wwwhomelessorguksitesdefaultfilessite-attachmentsThe unhealthy state of homelessness FINALpdf (accessed24 July 2018)


Killaspy H Ritchie CW Greer E and Robertson M (2004) ldquoTreating the homeless mentally ill does adesignated inpatient facility improve outcomerdquo Journal of Mental Health Vol 13 No 6 pp 593-9


Marmot M and Bell R (2012) ldquoFair society healthy livesrdquo Public Health Vol 126 pp S4-S10

Ministry of Housing Communities and Local Government (2017) ldquoRough sleeping statisticsrdquo available athttpsassetspublishingservicegovukgovernmentuploadssystemuploadsattachment_datafile682001Rough_Sleeping_Autumn_2017_Statistical_Release_-_revisedpdf (accessed 24 July 2018)

NICE (2016) ldquoTransition between inpatient mental health settings and community or care home settingsrdquoavailable at wwwniceorgukguidanceng53chapterRecommendationshospital-discharge (accessed24 July 2018)

OrsquoNeill A Casey P and Minton R (2007) ldquoThe homeless mentally ill ndash an audit from an inner city hospitalrdquoIrish Journal of Psychological Medicine Vol 24 No 2 pp 62-6

Pearson L (2010) ldquoSpecialist early psychosis intervention can prevent premature service disengagementand lower the risk of homelessnessrdquo Early Intervention in Psychiatry Vol 4 No 1 pp 38-187

Porter ME (2010) ldquoWhat is value in health carerdquo New England Journal of Medicine Vol 363 No 26pp 2477-81

Salize HJ Werner A and Jacke CO (2013) ldquoService provision for mentally disordered homeless peoplerdquoCurrent Opinion in Psychiatry Vol 26 No 4 pp 355-61

Stergiopoulos V Gozdzik A Nisenbaum R Lamanna D Hwang SW Tepper J and Wasylenki D(2017) ldquoIntegrating hospital and community care for homeless people with unmet mental health needs programrationale study protocol and sample description of a brief multidisciplinary case management interventionrdquoInternational Journal of Mental Health and Addiction Vol 15 No 2 pp 362-78

Stergiopoulos V Schuler A Nisenbaum R DeRuiter W Guimond T Wasylenki D Hoch JSHwang SW Rouleau K and Dewa C (2015) ldquoThe effectiveness of an integrated collaborative care modelvs a shifted outpatient collaborative care model on community functioning residential stability and healthservice use among homeless adults with mental illness a quasi-experimental studyrdquo BMC Health ServicesResearch Vol 15 No 1 p 348


Stringfellow EJ Kim TW Pollio DE and Kertesz SG (2015) ldquoPrimary care provider experience andsocial support among homeless-experienced persons with tri-morbidityrdquo Addiction Science amp ClinicalPractice Vol 10 No S1 p A64

Tulloch AD Khondoker MR Fearon P and David AS (2012) ldquoAssociations of homelessnessand residential mobility with length of stay after acute psychiatric admissionrdquo BMC Psychiatry Vol 12 No 1p 121

Windfuhr K and Kapur N (2011) ldquoSuicide and mental illness a clinical review of 15 years findings from theUK National Confidential Inquiry into Suiciderdquo British Medical Bulletin Vol 100 No 1 pp 101-21

Further reading






Covers13

Guest editorial

Hospital discharge planning for Canadians experiencing homelessness

The GP role in improving outcomes for homeless inpatients

Hospital collaboration with a Housing First program to improve health outcomes for people experiencing homelessness

Homeless medical respite service provision in the UK

The Cottage providing medical respite care in a home-like environment for people experiencing homelessness

Establishing a hospital healthcare team in a District General Hospital ndash transforming a model into a reality

Improving outcomes for homeless inpatients in mental health

Martin Whiteford and Michelle Cornes

Situating and understanding hospital discharge arrangements for homeless people

The importance of specialist hospital discharge arrangements for homeless people has beenwidely documented (see eg Whiteford and Simpson 2015 Albanese et al 2016 Corneset al 2018) Much of the work that has emerged to date has been dispersed across a broadrange of disciplinary fields (eg emergency medicine healthcare administration public healthand housing studies) and in consequence of this there has been a tendency to speak to discreteaudiences rather than say an explicit concern with fostering inter-disciplinary dialogue In theextant literature four main features stand out The first is the tendency to provide descriptiverather interpretative accounts of the role of specialist homeless healthcare teams The role ofclinicians features prominently in such accounts while the experiences and reflections ofhomeless patients have often been relegated to the margins The second feature is the overtfocus on hospital administrative data In such analyses hospital episode statistics (eg EDpresentations impatient admissions and emergency readmissions) are commonly used toillustrate the rates of healthcare utilisation among people who are homeless or at risk ofhomelessness The third characteristic is the cost of hospital services for homeless patients andor the effectiveness of community-based healthcare interventions (McCormick andWhite 2016)The fourth tendency is to examine medical respite care for homeless people (Doran et al 2013)Research in this area has consistently demonstrated the efficacy of medical respite for homelesspeople in terms of contributing to decreases in ED presentations as well as reductions in thenumber of unplanned inpatient days followed up by a period of recuperative care

Existing scholarship devoted to the issue of hospital discharge protocols and policies forhomeless people have tended to start from the position that people who are homeless oftenexperience poor hospital discharge arrangements (Blackburn et al 2017) Strong andcontinuous evidence has shown how unsafe discharge arrangements are costly at bothindividual and societal levels with many people who are homeless entering a cycle of hospitalreadmission which in turn serves to compound existing health inequalities Among practitionersand scholars there is a discernible (and oftentimes explicit) critique of ldquopatient dumpingrdquo ndash aphenomenon in which homeless patients are discharged not to temporary housing but to thestreets Indeed the failure to discharge homeless patients into appropriate accommodation isunderstood to lead to a cycle of poor health and episodic healthcare use This lack ofcoordinated care inevitably leads to emergency readmission and prolonged lengths of hospitalstay These factors by degrees place a significant burden on over-stretched and under-fundedhealthcare systems Framed in this way poor discharge practices and policies are commonlyconsidered to be a moral and economic abomination

Viewed from the other end of the telescope specialist hospital discharge arrangements forhomeless people are understood to be predicated on two overarching and intertwined concernsfirst a concern with turning off the spigot of ldquopatient dumpingrdquo and second a concern withactively engaging with the often complex and seemingly intractable housing and health needs ofpeople affected by homelessness These twin aims are it is argued best achieved throughensuring that housing and health needs are considered at the point of admission duringtreatment and post-discharge Together these concerns and aims have created a commonnarrative and policy agenda in the four main countries in the Anglosphere (ie the USA CanadaAustralia and the UK)

How did this happen To understand and contextualise the growing interest in homeless hospitaldischarge we must place it in the context of the paradigmatic shift towards auditing in healthcare

Martin Whiteford is based atthe Health Services ResearchUniversity of LiverpoolLiverpool UKMichelle Cornes is based at theNIHR Health and Social CareWorkforce Research UnitKings College LondonLondon UK


Guest editorial






Note


References














Abstract









Canadian context





Literature review







Research question



Methodology




Findings

Demographics


Scope of the issue





Barriers and gaps


Communication



nfrac14660 n n





Privacy








x Median Mode



Systems pressures



Discussion








Limitations




Conclusion


References























































Abstract




Introduction









Method






































Masters or PhD



























deaths

Cancer diagnosis



significant events




















Outcome data







Discussion








References












































Abstract




1 Background
























2 Methods

21 Data sources






22 Analysis


23 Ethics approval


3 Results


















































4 Discussion





















41 Limitations







5 Conclusions





References





































Author Affiliations







About the authors











Abstract




Introduction











Literature review

Methodology










































Patient categories























London ()

69 clients ndash

























































Payment principles






Housing benefit



Joint commissioning




Summary




References










































Further reading




About the authors












Abstract




Background














Aims


Methods










Client case studies


Results

Client demographics

























Case studies


























Discussion










Limitations




Conclusions



References






























About the authors










Abstract




Introduction























Case studies


Research findings





Key points








Key points






Key points






Key points




Staff education



Key points






Key points















Lessons learned











Lessons learned







Lessons learned




Lessons learned



Staff education



Lessons learned






Lessons learned



Future aims













Personal reflection







References


































Abstract




Introduction








Method








Service attributes

Overview



Service development






Referral criteria


18+







Service model


















Southwark LawCentre



Departments





providersCMHTs


No RecourseTeams






servicesEmbassies


and support







Food banks



Housing worker


GP


Business manager


Clinical academics




andRisk Assessment


Reconnection

Housingsupport


up

Practicalassistance


FrequentAttender

Work

Challengingpractice

CommunityAccess

Advocacy



Sta

ff Tr

aini

ng

Care C

oordinator Advice







Reconnection













Evaluation findings






Cost savings



















































Discussion










References


































Further reading






Covers13

Guest editorial













Note


References














Abstract









Canadian context





Literature review







Research question



Methodology




Findings

Demographics


Scope of the issue





Barriers and gaps


Communication



nfrac14660 n n





Privacy








x Median Mode



Systems pressures



Discussion








Limitations




Conclusion


References























































Abstract




Introduction









Method






































Masters or PhD



























deaths

Cancer diagnosis



significant events




















Outcome data







Discussion








References












































Abstract




1 Background
























2 Methods

21 Data sources






22 Analysis


23 Ethics approval


3 Results


















































4 Discussion





















41 Limitations







5 Conclusions





References





































Author Affiliations







About the authors











Abstract




Introduction











Literature review

Methodology










































Patient categories























London ()

69 clients ndash

























































Payment principles






Housing benefit



Joint commissioning




Summary




References










































Further reading




About the authors












Abstract




Background














Aims


Methods










Client case studies


Results

Client demographics

























Case studies


























Discussion










Limitations




Conclusions



References






























About the authors










Abstract




Introduction























Case studies


Research findings





Key points








Key points






Key points






Key points




Staff education



Key points






Key points















Lessons learned











Lessons learned







Lessons learned




Lessons learned



Staff education



Lessons learned






Lessons learned



Future aims













Personal reflection







References


































Abstract




Introduction








Method








Service attributes

Overview



Service development






Referral criteria


18+







Service model


















Southwark LawCentre



Departments





providersCMHTs


No RecourseTeams






servicesEmbassies


and support







Food banks



Housing worker


GP


Business manager


Clinical academics




andRisk Assessment


Reconnection

Housingsupport


up

Practicalassistance


FrequentAttender

Work

Challengingpractice

CommunityAccess

Advocacy



Sta

ff Tr

aini

ng

Care C

oordinator Advice







Reconnection













Evaluation findings






Cost savings



















































Discussion










References


































Further reading






Covers13

Guest editorial










Abstract









Canadian context





Literature review







Research question



Methodology




Findings

Demographics


Scope of the issue





Barriers and gaps


Communication



nfrac14660 n n





Privacy








x Median Mode



Systems pressures



Discussion








Limitations




Conclusion


References























































Abstract




Introduction









Method






































Masters or PhD



























deaths

Cancer diagnosis



significant events




















Outcome data







Discussion








References












































Abstract




1 Background
























2 Methods

21 Data sources






22 Analysis


23 Ethics approval


3 Results


















































4 Discussion





















41 Limitations







5 Conclusions





References





































Author Affiliations







About the authors











Abstract




Introduction











Literature review

Methodology










































Patient categories























London ()

69 clients ndash

























































Payment principles






Housing benefit



Joint commissioning




Summary




References










































Further reading




About the authors












Abstract




Background














Aims


Methods










Client case studies


Results

Client demographics

























Case studies


























Discussion










Limitations




Conclusions



References






























About the authors










Abstract




Introduction























Case studies


Research findings





Key points








Key points






Key points






Key points




Staff education



Key points






Key points















Lessons learned











Lessons learned







Lessons learned




Lessons learned



Staff education



Lessons learned






Lessons learned



Future aims













Personal reflection







References


































Abstract




Introduction








Method








Service attributes

Overview



Service development






Referral criteria


18+







Service model


















Southwark LawCentre



Departments





providersCMHTs


No RecourseTeams






servicesEmbassies


and support







Food banks



Housing worker


GP


Business manager


Clinical academics




andRisk Assessment


Reconnection

Housingsupport


up

Practicalassistance


FrequentAttender

Work

Challengingpractice

CommunityAccess

Advocacy



Sta

ff Tr

aini

ng

Care C

oordinator Advice







Reconnection













Evaluation findings






Cost savings



















































Discussion










References


































Further reading






Covers13

Guest editorial









Canadian context





Literature review







Research question



Methodology




Findings

Demographics


Scope of the issue





Barriers and gaps


Communication



nfrac14660 n n





Privacy








x Median Mode



Systems pressures



Discussion








Limitations




Conclusion


References























































Abstract




Introduction









Method






































Masters or PhD



























deaths

Cancer diagnosis



significant events




















Outcome data







Discussion








References












































Abstract




1 Background
























2 Methods

21 Data sources






22 Analysis


23 Ethics approval


3 Results


















































4 Discussion





















41 Limitations







5 Conclusions





References





































Author Affiliations







About the authors











Abstract




Introduction











Literature review

Methodology










































Patient categories























London ()

69 clients ndash

























































Payment principles






Housing benefit



Joint commissioning




Summary




References










































Further reading




About the authors












Abstract




Background














Aims


Methods










Client case studies


Results

Client demographics

























Case studies


























Discussion










Limitations




Conclusions



References






























About the authors










Abstract




Introduction























Case studies


Research findings





Key points








Key points






Key points






Key points




Staff education



Key points






Key points















Lessons learned











Lessons learned







Lessons learned




Lessons learned



Staff education



Lessons learned






Lessons learned



Future aims













Personal reflection







References


































Abstract




Introduction








Method








Service attributes

Overview



Service development






Referral criteria


18+







Service model


















Southwark LawCentre



Departments





providersCMHTs


No RecourseTeams






servicesEmbassies


and support







Food banks



Housing worker


GP


Business manager


Clinical academics




andRisk Assessment


Reconnection

Housingsupport


up

Practicalassistance


FrequentAttender

Work

Challengingpractice

CommunityAccess

Advocacy



Sta

ff Tr

aini

ng

Care C

oordinator Advice







Reconnection













Evaluation findings






Cost savings



















































Discussion










References


































Further reading






Covers13

Guest editorial








Housing, Care and Support

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Transcript of Housing, Care and Support