Taking a holistic approach to treating homeless people attending emergency departments is helping to break the cycle of homelessness

Between 400 to 600 homeless people attend Emergency Departments (ED) at Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) every year. Kim Forey, Director of Integration at One Gloucestershire, discusses with colleagues across the health and care system how taking a holistic approach to treating homelessness and investing in greater care and support of this vulnerable group is having a meaningful impact.

Kim explained:

“The statistics are startling and show that there are avoidable and unfair differences in the way homeless people experience care. Around a third of homeless deaths are the results of treatable medical conditions and homeless people are likely to attend ED six times more frequently than the housed population and stay in hospital for three times as long.

“Homelessness is a very complex problem which can be caused by a number of different factors which can be very challenging to treat. Trauma has often played a key part in influencing someone’s journey to homelessness.  Until we look at the person as a whole and work out what the multiple and complex factors are that played a major part in getting them into the situation they are in, we can’t begin to help that person.

“Once we complete the puzzle of their lives, we can start to think about why they are using ED so frequently and what kind of help and interventions will get them back on track after discharge. We are stronger and more efficient when we look at this as a partnership.”

A project from the frontline of healthcare provided the catalyst for change

A homeless patient project in ED at GHNHSFT was the catalyst for change This led to an approach being made to the Gloucestershire Strategic Housing Partnership (SHP) – a partnership made up of the six district councils, the county council and the Integrated Care Board (ICB). By working as a wider partnership with the local authority and voluntary and community sector organisations (VCS), health and care professionals joined forces to make sure homeless patients received the right support following discharge from ED.

The quality improvement (QI) project focused on developing a pathway for supporting homeless ED attenders. Professionals are now able to help homeless patients access accommodation directly from ED. Along with two new dedicated support roles within the community support service, this streamlined process has improved the standard of care experienced by vulnerable homeless patients.

Shona Duffy became the Homeless Specialist Nurse at GHT and her idea sparked the project. Her expertise working within a safeguarding team had already given her an insight into why homeless people use healthcare services more frequently.

However, it was a winter stint volunteering at a local night shelter that provided her with deeper knowledge of how this group experiences inequalities and barriers to care. Identifying frequent users of ED with the aim of providing better care and reducing A&E attendances while aligning process with The Homeless Reduction Act 2017 (HRA) were the central planks of the project. The HRA puts a legal duty on all trusts to refer those who are homeless, or at risk of homelessness, to a local authority within 56 days. Prior to the project, there were no processes in place at GHNHSFT at to ensure this legislation was followed.

She added:

“I knew from clinical practice that we were discharging people back on to the streets without support, meaning they were facing the same issues as part of a vicious circle,” said Shona.

“All that was happening was that they were coming back to ED time and time again”

Neil Penny Health and Social Care Commissioning Manager for One Gloucestershire has evaluated Shona’s role.

He said:

“When we met Shona her passion for this area of work shone through.”

“It also seemed like this role could make a huge difference to people’s lives. We had already commissioned the Time to Heal service to support hospital discharge for homeless people, but the idea of having someone at the ‘front door’ felt like it would really complement their role.”

Trying a different approach was the key

Shona explained:

“The focus of the project was really simple and straightforward – we didn’t have a project plan or a business case, but we had data which helped us identify a trend in homeless people using A&E. The project came straight from ‘the frontline’ of healthcare”.

“The idea was that if we picked up someone at the ‘front door’ and kept them in for a few days, we could reduce the time they spent in hospital in the longer term. We knew that we had to look at the wider picture of what was happening in someone’s life if we wanted change.”

A cultural shift in attitudes towards people who are homeless has driven success

Staff working in ED have experienced a cultural shift after being taught about the tri-morbidity of homelessness (which means a homeless person is more likely to suffer from mental ill health, physical ill health, and substance misuse and at the same time is likely to access services). Education about homelessness empowers professionals to swiftly identify the risks to patients who experience tri-morbidity so that support can be put in place sooner.

Shona, whose role sits within GHT’s Safeguarding Team, and her colleagues worked closely with the P3 charity which provides housing support services and homelessness prevention among other support. The data shows how effective the project has been. Looking at a sample of 10 patients, analysis covers 11 months before and after the implementation of a personalised support plan (PSP) by the Homeless Specialist Nurse and the P3 in-reach hospital navigator and/or ELIM Time to Heal housing officer.

These 10 homeless patients collectively attended ED 221 times during the 11 months before their plans began and 52 times during the 11 months after their plans started.  As expected, the decrease in ED attendances caused the total hours spent in ED by these 10 patients across 11 months to decrease from 900 hours to 226 hours.

Since plans for these 10 patients took root, comparing 11 months pre-plan to 11 months post-plan, there has been a total reduction of 161 ED attendances. This equates to 674 hours spent in ED.

Also for frequent attenders at ED, the top 10 in the Trust used to include some rough sleepers (as is the case regionally and nationally). Currently there isn’t a homeless person in top 30 frequent attenders and none of the top 10 most frequent attenders are homeless.  This is a striking comparison with 2020 when seven out of the top 10 frequent attenders were homeless. GHNHSFT is the only acute trust in the South West which currently has no homeless frequent attenders.*

Partnership working strengthened the project

Working as a partnership between clinicians, commissioners and local services has meant a huge reduction in ‘bed days’ (the number of days during which a hospital bed is occupied). Close working between health, housing and support providers has also significantly reduced police and ambulance time as the person becomes more settled generally and begins to reduce reliance on emergency service contact.

Neil added:

“Our primary consideration was ‘what if we could stop people coming into the hospital in the first place’? Once we’d made the case to the Strategic Housing Partnership they were in full agreement to fund Shona’s role to see if it could work. The results have been fantastic and the data shows the huge difference being made.”

More information

For more information, go to www.onegloucestershire.net/

The project recently won the NHS Safeguarding Award at the HSJ Patient safety Awards 2022. The judges described it as a ‘clear winner with fantastic outcomes and impact’.

Read more about the award here: https://www.hsj.co.uk/patient-safety-awards/hsj-patient-safety-awards-2022-nhs-safeguarding-award/7033098.article