Nigel Hewett

Purpose: People experiencing homelessness often have complex needs requiring a range of support. These may include health problems (physical illness, mental health and/or substance misuse) as well as social, financial and housing needs. Addressing these issues requires a high degree of coordination amongst services. It is, thus, an example of a wicked policy issue. The purpose of this paper is to examine the challenge of integrating care in this context using evidence from an evaluation of English hospital discharge services for people experiencing homelessness.Design/methodology/approach: The paper undertakes secondary analysis of qualitative data from a mixed methods evaluation of hospital discharge schemes and uses an established framework for understanding integrated care, the Rainbow Model of Integrated Care (RMIC), to help examine the complexities of integration in this area.Findings: Supporting people experiencing homelessness to have a good discharge from hospital was confirmed as a wicked policy issue. The RMIC provided a strong framework for exploring the concept of integration, demonstrating how intertwined the elements of the framework are and, hence, that solutions need to be holistically organised across the RMIC. Limitations to integration were also highlighted, such as shortages of suitable accommodation and the impacts of policies in aligned areas of the welfare state.Research limitations/implications: The data for this secondary analysis were not specifically focussed on integration which meant the themes in the RMIC could not be explored directly nor in as much depth. However, important issues raised in the data directly related to integration of support, and the RMIC emerged as a helpful organising framework for understanding integration in this wicked policy context.Practical implications: Integration is happening in services directly concerned with the discharge from hospital of people experiencing homelessness. Key challenges to this integration are reported in terms of the RMIC, which would be a helpful framework for planning better integrated care for this area of practice.Social implications: Addressing homelessness not only requires careful planning of integration of services at specific pathway points, such as hospital discharge, but also integration across wider systems. A complex set of challenges are discussed to help with planning the better integration desired, and the RMIC was seen as a helpful framework for thinking about key issues and their interactions.Originality/value: This paper examines an application of integrated care knowledge to a key complex, or wicked policy issue.

Background: UK “Pathway” teams offer specialist hospital care coordination for people experiencing homelessness. Emergency healthcare use is high among homeless people, yet “homelessness” is not routinely coded in National Health Service (NHS) data. Pathway team records provide an opportunity to assess patterns in admissions and outcomes for inpatients identified as homeless. Methods: Retrospective analysis of patients referred to “Pathway” homelessness teams in seven UK hospitals to explore the patterns of hospital admission, morbidity, secondary healthcare utilisation and housing status. Each patient was individually identified as experiencing homelessness. Within a six-month period, demographic data, reason for admission, morbidity, mortality and secondary care hospital usage 120-days before and 120-days after the index admission was collected. Results: A total of 1009 patients were referred, resulting in 1135 admissions. Most admissions had an acute physical health need (94.9%). Co-morbid mental illness and/or substance misuse was common (55.7%). Reasons for admission included mental and behavioral disorders (overdose, alcohol withdrawal or depression, 28.3%), external causes of morbidity and mortality (assault or trauma, 18.7%), and injury, poisoning and external causes (head injury, falls and fractures, 12.4%). Unplanned Emergency Department attendances reduced after index admission and unplanned hospital admissions increased slightly. Planned admissions doubled and total bed days increased. Housing status was maintained or improved for over 60% of inpatients upon discharge. Within 12 months of index admission, 50 patients (5%) died, 15 deaths (30%) occurred during the index admission. Conclusions: Disengagement with health services is common among homeless people. Many deaths are due to treatable medical conditions (heart disease, pneumonia, cancer). Observed increases in planned admissions suggests intervention from Pathway teams facilitates necessary investigations and treatment for homeless people. Equity, parity of care, and value should be inbuilt interventions for inclusion health groups and evaluations need to move beyond simply seeking cost reductions.

Purpose: The purpose of this paper is to review the history and current state of provision of homeless medical respite services in the UK, drawing first on the international context. The paper then articulates the need for medical respite services in the UK, and profiles some success stories. The paper then outlines the considerable challenges that currently exist in the UK, considers why some other services have failed and proffers some solutions. Design/methodology/approach: The paper is primarily a literature review, but also offers original analysis of data and interviews, and presents new ideas from the authors. All authors have considerable experience of assessing the need for and delivering homeless medical respite services. Findings: The paper builds on previous published information regarding need, and articulates the human rights argument for commissioning care. The paper also discusses the current complex commissioning arena, and suggests solutions. Research limitations/implications: The literature review was not a systematic review, but was conducted by authors with considerable experience in the field. Patient data quoted are on two limited cohorts of patients, but broadly relevant. Interviews with stakeholders regarding medical respite challenges have been fairly extensive, but may not be comprehensive. Practical implications: This paper will support those who are thinking of undertaking a needs assessment for medical respite, or commissioning a new medical respite service, to understand the key issues involved. Social implications: This paper challenges the existing status quo regarding the need for a “cost-saving” rationale to set up these services. Originality/value: This paper aims to be the definitive paper for anyone wishing to get an overview of this topic.

An increasing body of research demonstrates that homelessness is an independent risk factor for morbidity and premature death. This paper compares the frequency of diagnoses between 2003 and 2009 in the computerised records of a specialist practice for homeless people. The changing morbidity trends revealed offer a basis for comparison with other services and suggest benefits from collaborative working, particularly around substance misuse and mental health.