1
|
Luchenski S, Aldridge R, Stevenson F, Tariq S, Hewett N, Hayward A. Hospital admissions for physical health and psychosocial adversity among people experiencing homelessness in England: a population-based retrospective cross-sectional study. Lancet 2023; 402 Suppl 1:S10. [PMID: 37997049 DOI: 10.1016/s0140-6736(23)02061-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/20/2023] [Accepted: 09/22/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Homeless health care is often characterised by physical health, mental health, and substance use problems, resulting in high use of emergency care, poor outcomes, and extreme social inequities. We assessed health needs as prevention opportunities for hospitalised people experiencing homelessness (PEH) in England. METHODS This population-based retrospective cross-sectional study used anonymised national Hospital Episodes Statistics Admitted Patient Care data. PEH were identified as having at least one homeless code ("no fixed abode", "registered with a homeless-exclusive GP practice", "clinical diagnosis of homelessness") from April 1, 2017, to March 31, 2018. We analysed admissions for PEH and for housed people. We estimated the prevalence of demographic and admission characteristics and diagnoses by 10th International Classification of Disease (ICD-10) chapter. We developed novel diagnostic phenotypes for physical health (internal disease processes) and psychosocial adversity (mental health, substance use, violence, and social factors). We compared admissions between PEH and housed people using sex-stratified logistic regression adjusted for age and ethnicity. FINDINGS There were 15 566 010 admissions (51 643 PEH and 15 514 367 housed people). Compared with housed people, proportionately more PEH were younger (PEH aged 26-45 years, n=24 224 [46·9%], housed people n=3 323 951 [21·4%]), male (PEH n=37 662 [72·9%], housed people n=6 819 157 [44·0%]), and not White British (PEH n=14 605 [28·3%], housed people n=3 447 183 [22·2%]). Emergency admissions were more common among PEH (PEH male n=30 958 [82·2%], housed people male n=5 321 428 [34·3%], adjusted odds ratio [aOR] 8·76, 95% CI 8·53-9·00). The most common primary diagnoses by ICD-10 chapter for PEH were mental and behavioural conditions (PEH male n=7118 admissions [18·9%], housed people male n=155 144 [1·0%], 12·97, 12·61-13·34). Admissions for the psychosocial adversity phenotype were higher in PEH, particularly for women (PEH female n=3922 [28·1%], housed people female n=155 644 [1·79%], 18·18, 17·50-18·88). Physical health phenotype admissions were less common in PEH (PEH male n=7510 [19·9%], housed people male n=1 821 397 [26·7%], 0·91, 0·89-0·94), but specific infections, cancers, respiratory, and cardiovascular diseases were more common among PEH for both men and women. INTERPRETATION These results support targeting of preventative interventions for PEH before, during and after admission to hospital, highlighting psychosocial needs. Future research should aim to produce reliable estimates of the size of the national homeless population to enable calculation of admission rates for psychosocial and physical health diagnoses. FUNDING National Institute for Health and Care Research (NIHR).
Collapse
Affiliation(s)
- Serena Luchenski
- Collaborative Centre for Inclusion Health, University College London, London, UK.
| | - Rob Aldridge
- Centre for Public Health Data Science, University College London, London, UK
| | - Fiona Stevenson
- Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Shema Tariq
- Institute of Global Health, University College London, London, UK
| | | | - Andrew Hayward
- Collaborative Centre for Inclusion Health, University College London, London, UK
| |
Collapse
|
2
|
Tulloch AD, Khan Z, Hewett N, Koehne S, Rao R. Evaluation of a Pathway team for homeless mental health in-patients. BJPsych Bull 2023; 47:255-262. [PMID: 36872081 PMCID: PMC10764855 DOI: 10.1192/bjb.2022.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 09/06/2022] [Accepted: 09/10/2022] [Indexed: 03/07/2023] Open
Abstract
AIMS AND METHOD The Pathway model is an enhanced care coordination model for homeless people in hospital. We aimed to evaluate the first attempt to apply it on psychiatric wards, which started in 2015 in South London. We developed a logic model which expressed how the Pathway approach might work. Two predictions from this model were tested, using propensity scores and regression to estimate the effect of the intervention among people who were eligible for it. RESULTS The Pathway team theorised that their interventions would reduce length of stay, improve housing outcomes and optimise the use of primary care - and, more tentatively, reduce readmission and emergency presentations. We were able to estimate effects on length of stay (-20.3 days; 95% CI -32.5 to -8.1; P = 0.0012) and readmission (a non-significant reduction). CLINICAL IMPLICATIONS The marked reduction in length of stay, explicable in terms of the logic model, constitutes preliminary support for the Pathway model in mental health services.
Collapse
Affiliation(s)
- Alex D. Tulloch
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, UK
| | - Zana Khan
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Sophie Koehne
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Ranga Rao
- South London and Maudsley NHS Foundation Trust, London, UK
| |
Collapse
|
3
|
Luchenski SA, Dawes J, Aldridge RW, Stevenson F, Tariq S, Hewett N, Hayward AC. Hospital-based preventative interventions for people experiencing homelessness in high-income countries: A systematic review. EClinicalMedicine 2022; 54:101657. [PMID: 36311895 PMCID: PMC9597099 DOI: 10.1016/j.eclinm.2022.101657] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 08/15/2022] [Accepted: 08/29/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND People experiencing homelessness have significant unmet needs and high rates of unplanned care. We aimed to describe preventative interventions, defined in their broadest sense, for people experiencing homelessness in a hospital context. Secondary aims included mapping outcomes and assessing intervention effectiveness. METHODS We searched online databases (MEDLINE, Embase, PsycINFO, HMIC, CINAHL, Web of Science, Cochrane Library) from 1999-2019 and conducted backward and forward citation searches to 31 December 2020 (PROSPERO CRD42019154036). We included quantitative studies in emergency and inpatient settings measuring health or social outcomes for adults experiencing homelessness in high income countries. We assessed rigour using the "Quality Assessment Tool for Quantitative Studies" and summarised findings using descriptive quantitative methods, a binomial test, a Harvest Plot, and narrative synthesis. We used PRISMA and SWiM reporting guidelines. FINDINGS Twenty-eight studies identified eight intervention types: care coordination (n=18); advocacy, support, and outreach (n=13); social welfare assistance (n=13); discharge planning (n=12); homelessness identification (n=6); psychological therapy and treatment (n=6); infectious disease prevention (n=5); and screening, treatment, and referrals (n=5). The evidence strength was weak (n=16) to moderate (n=10), with two high quality randomised controlled trials. We identified six outcome categories with potential benefits observed for psychosocial outcomes, including housing (11/13 studies, 95%CI=54.6-98.1%, p=0.023), healthcare use (14/17, 56.6-96.2%, p=0.013), and healthcare costs (8/8, 63.1-100%, p=0.008). Benefits were less likely for health outcomes (4/5, 28.3-99.5%, p=0.375), integration with onward care (2/4, 6.8-93.2%, p=1.000), and feasibility/acceptability (5/6, 35.9-99.6%, p=0.219), but confidence intervals were very wide. We observed no harms. Most studies showing potential benefits were multi-component interventions. INTERPRETATION Hospital-based preventative interventions for people experiencing homelessness are potentially beneficial, but more rigorous research is needed. In the context of high needs and extreme inequities, policymakers and healthcare providers may consider implementing multi-component preventative interventions. FUNDING SL is supported by an NIHR Clinical Doctoral Research Fellowship (ICA-CDRF-2016-02-042). JD is supported by an NIHR School of Public Health Research Pre-doctoral Fellowship (NU-004252). RWA is supported by a Wellcome Clinical Research Career Development Fellowship (206602).
Collapse
Affiliation(s)
- Serena A. Luchenski
- Collaborative Centre for Inclusion Health, Institute of Epidemiology and Healthcare, University College London, 1-19 Torrington Place, London WC1E 7HT, United Kingdom
- Corresponding author.
| | - Joanna Dawes
- Collaborative Centre for Inclusion Health, Institute of Epidemiology and Healthcare, University College London, 1-19 Torrington Place, London WC1E 7HT, United Kingdom
| | - Robert W. Aldridge
- Centre for Public Health Data Science, Institute for Health Informatics, University College London, 255 Euston Road, London NW1 2DA, United Kingdom
| | - Fiona Stevenson
- Department of Primary Care and Population Health, Institute of Epidemiology and Healthcare, University College London, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, United Kingdom
| | - Shema Tariq
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, Mortimer Market Centre, off Capper Street, London WC1E 6JB, United Kingdom
| | - Nigel Hewett
- Pathway, 4th Floor, East, 250 Euston Rd, London NW1 2PG, United Kingdom
| | - Andrew C. Hayward
- Collaborative Centre for Inclusion Health, Institute of Epidemiology and Healthcare, University College London, 1-19 Torrington Place, London WC1E 7HT, United Kingdom
| |
Collapse
|
4
|
Tinelli M, Wittenberg R, Cornes M, Aldridge RW, Clark M, Byng R, Foster G, Fuller J, Hayward A, Hewett N, Kilmister A, Manthorpe J, Neale J, Biswell E, Whiteford M. The economic case for hospital discharge services for people experiencing homelessness in England: An in-depth analysis with different service configurations providing specialist care. Health Soc Care Community 2022; 30:e6194-e6205. [PMID: 36205443 PMCID: PMC10092708 DOI: 10.1111/hsc.14057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 08/11/2022] [Accepted: 09/12/2022] [Indexed: 06/16/2023]
Abstract
There are long-standing concerns that people experiencing homelessness may not recover well if left unsupported after a hospital stay. This study reports on a study investigating the cost-effectiveness of three different 'in patient care coordination and discharge planning' configurations for adults experiencing homelessness who are discharged from hospitals in England. The first configuration provided a clinical and housing in-reach service during acute care and discharge coordination but with no 'step-down' care. The second configuration provided clinical and housing in-reach, discharge coordination and 'step-down' intermediate care. The third configuration consisted of housing support workers providing in-reach and discharge coordination as well as step-down care. These three configurations were each compared with 'standard care' (control, defined as one visit by the homelessness health nurse before discharge during which patients received an information leaflet on local services). Multiple sources of data and multi-outcome measures were adopted to assess the cost utility of hospital discharge service delivery for the NHS and broader public perspective. Details of 354 participants were collated on service delivery costs (salary, on-costs, capital, overheads and 'hotel' costs, advertising and other indirect costs), the economic consequences for different public services (e.g. NHS, social care, criminal justice, housing, etc.) and health utilities (quality-adjusted-life-years, QALYs). Findings were complex across the configurations, but, on the whole, there was promising evidence suggesting that, with delivery costs similar to those reported for bed-based intermediate care, step-down care secured better health outcomes and improved cost-effectiveness (compared with usual care) within NICE cost-effectiveness recommendations.
Collapse
Affiliation(s)
- Michela Tinelli
- Care Policy and Evaluation CentreThe London School of Economics and Political ScienceLondonUK
| | - Raphael Wittenberg
- Care Policy and Evaluation CentreThe London School of Economics and Political ScienceLondonUK
| | - Michelle Cornes
- NIHR Policy Research Unit in Health and Social Care WorkforceLondonUK
| | - Robert W. Aldridge
- Institute of Health Informatics, University College London Department of Epidemiology and Public Health, Institute of Epidemiology and Health CareLondonUK
| | - Michael Clark
- Care Policy and Evaluation CentreThe London School of Economics and Political ScienceLondonUK
| | - Richard Byng
- Community and Primary Care Research Group, Peninsula School of MedicineUniversity of Plymouth, ITTCPlymouthUK
| | - Graham Foster
- Blizard Institute, Queen Mary University of LondonLondonUK
| | - James Fuller
- NIHR Policy Research Unit in Health and Social Care WorkforceLondonUK
| | - Andrew Hayward
- Institute of Health Informatics, University College London Department of Epidemiology and Public Health, Institute of Epidemiology and Health CareLondonUK
| | - Nigel Hewett
- Pathway and the Faculty for Homeless and Inclusion HealthLondonUK
| | - Alan Kilmister
- NIHR Policy Research Unit in Health and Social Care WorkforceLondonUK
| | - Jill Manthorpe
- NIHR Policy Research Unit in Health and Social Care WorkforceLondonUK
| | - Joanne Neale
- National Addiction CentreInstitute of Psychiatry, Psychology & Neuroscience, King's College London, Addictions Sciences BuildingLondonUK
| | - Elizabeth Biswell
- NIHR Policy Research Unit in Health and Social Care WorkforceLondonUK
| | - Martin Whiteford
- Department of Community Nursing and Community HealthGlasgow Caledonian UniversityGlasgowUK
| |
Collapse
|
5
|
Armstrong M, Shulman C, Hudson B, Stone P, Hewett N. Barriers and facilitators to accessing health and social care services for people living in homeless hostels: a qualitative study of the experiences of hostel staff and residents in UK hostels. BMJ Open 2021; 11:e053185. [PMID: 34663667 PMCID: PMC8524272 DOI: 10.1136/bmjopen-2021-053185] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The number of people living in homeless hostels in the UK has steadily increased over the past decade. Despite people experiencing homelessness often having considerable health problems and a range of complex needs frequently in association with addictions, the experiences of hostel staff and residents especially in relation to accessing health and social care support have seldom been explored. The aim of this paper is to identify the barriers and facilitators to accessing health and social care services for people living in homeless hostels. DESIGN Exploratory qualitative baseline data were collected as part of an intervention to facilitate palliative care in-reach into hostels. SETTING/PARTICIPANTS Interviews were conducted with 33 participants; 18 homeless hostel managers/support staff and 15 people experiencing homelessness, from six homeless hostels in London and Kent. RESULTS Three themes were identified (1) internal and external service barriers to health and social care access due to stigma, lack of communication and information sharing from services and assumptions around capacity and the role of the hostel, (2) the impact of lack of health and social care support on hostel staff leading to burnout, staff going beyond their job role and continuous support given to residents, (3) potential facilitators to health and social care access such in-reach and support from those who understand this population and hostel staff training. DISCUSSION Residents have multiple complex needs yet both hostel staff and residents face stigma and barriers accessing support from external services. Positive relationships were described between hostel residents and staff, which can be an essential step in engaging with other services. People experiencing homelessness urgently need better access to person-centred, trauma-informed support ideally via in-reach from people who understand the needs of the population.
Collapse
Affiliation(s)
- Megan Armstrong
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Caroline Shulman
- Marie Curie Palliative Care Research Department, University College London, London, UK
- Pathway Charity, London, UK
| | | | - Patrick Stone
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | | |
Collapse
|
6
|
Cornes M, Aldridge RW, Biswell E, Byng R, Clark M, Foster G, Fuller J, Hayward A, Hewett N, Kilmister A, Manthorpe J, Neale J, Tinelli M, Whiteford M. Improving care transfers for homeless patients after hospital discharge: a realist evaluation. Health Serv Deliv Res 2021. [DOI: 10.3310/hsdr09170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
In 2013, 70% of people who were homeless on admission to hospital were discharged back to the street without having their care and support needs addressed. In response, the UK government provided funding for 52 new specialist homeless hospital discharge schemes. This study employed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines between September 2015 and 2019 to undertake a realist evaluation to establish what worked, for whom, under what circumstances and why. It was hypothesised that delivering outcomes linked to consistently safe, timely care transfers for homeless patients would depend on hospital discharge schemes implementing a series of high-impact changes (resource mechanisms). These changes encompassed multidisciplinary discharge co-ordination (delivered through clinically led homeless teams) and ‘step-down’ intermediate care. These facilitated time-limited care and support and alternative pathways out of hospital for people who could not go straight home.
Methods
The realist hypothesis was tested empirically and refined through three work packages. Work package 1 generated seven qualitative case studies, comparing sites with different types of specialist homeless hospital discharge schemes (n = 5) and those with no specialist discharge scheme (standard care) (n = 2). Methods of data collection included interviews with 77 practitioners and stakeholders and 70 people who were homeless on admission to hospital. A ‘data linkage’ process (work package 2) and an economic evaluation (work package 3) were also undertaken. The data linkage process resulted in data being collected on > 3882 patients from 17 discharge schemes across England. The study involved people with lived experience of homelessness in all stages.
Results
There was strong evidence to support our realist hypothesis. Specialist homeless hospital discharge schemes employing multidisciplinary discharge co-ordination and ‘step-down’ intermediate care were more effective and cost-effective than standard care. Specialist care was shown to reduce delayed transfers of care. Accident and emergency visits were also 18% lower among homeless patients discharged at a site with a step-down service than at those without. However, there was an impact on the effectiveness of the schemes when they were underfunded or when there was a shortage of permanent supportive housing and longer-term care and support. In these contexts, it remained (tacitly) accepted practice (across both standard and specialist care sites) to discharge homeless patients to the streets, rather than delay their transfer. We found little evidence that discharge schemes fired a change in reasoning with regard to the cultural distance that positions ‘homeless patients’ as somehow less vulnerable than other groups of patients. We refined our hypothesis to reflect that high-impact changes need to be underpinned by robust adult safeguarding.
Strengths and limitations
To our knowledge, this is the largest study of the outcomes of homeless patients discharged from hospital in the UK. Owing to issues with the comparator group, the effectiveness analysis undertaken for the data linkage was limited to comparisons of different types of specialist discharge scheme (rather than specialist vs. standard care).
Future work
There is a need to consider approaches that align with those for value or alliance-based commissioning where the evaluative gaze is shifted from discrete interventions to understanding how the system is working as a whole to deliver outcomes for a defined patient population.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 17. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Michelle Cornes
- Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Robert W Aldridge
- Institute of Health Informatics, University College London, London, UK
| | - Elizabeth Biswell
- Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Richard Byng
- Clinical Trials and Health Research, University of Plymouth, Plymouth, UK
| | - Michael Clark
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Graham Foster
- Blizard Institute, Queen Mary University of London, London, UK
| | - James Fuller
- Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Andrew Hayward
- Institute of Health Informatics, University College London, London, UK
| | - Nigel Hewett
- Pathway and the Faculty for Homeless and Inclusion Health, London, UK
| | - Alan Kilmister
- Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Jill Manthorpe
- Health and Social Care Workforce Research Unit, King’s College London, London, UK
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Michela Tinelli
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Martin Whiteford
- Department of Community Nursing and Community Health, Glasgow Caledonian University, Glasgow, UK
| |
Collapse
|
7
|
Lewer D, Menezes D, Cornes M, Blackburn RM, Byng R, Clark M, Denaxas S, Evans H, Fuller J, Hewett N, Kilmister A, Luchenski SA, Manthorpe J, McKee M, Neale J, Story A, Tinelli M, Whiteford M, Wurie F, Yavlinsky A, Hayward A, Aldridge R. Hospital readmission among people experiencing homelessness in England: a cohort study of 2772 matched homeless and housed inpatients. J Epidemiol Community Health 2021; 75:681-688. [PMID: 33402395 PMCID: PMC8223662 DOI: 10.1136/jech-2020-215204] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/06/2020] [Accepted: 12/04/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Inpatients experiencing homelessness are often discharged to unstable accommodation or the street, which may increase the risk of readmission. METHODS We conducted a cohort study of 2772 homeless patients discharged after an emergency admission at 78 hospitals across England between November 2013 and November 2016. For each individual, we selected a housed patient who lived in a socioeconomically deprived area, matched on age, sex, hospital, and year of discharge. Counts of emergency readmissions, planned readmissions, and Accident and Emergency (A&E) visits post-discharge were derived from national hospital databases, with a median of 2.8 years of follow-up. We estimated the cumulative incidence of readmission over 12 months, and used negative binomial regression to estimate rate ratios. RESULTS After adjusting for health measured at the index admission, homeless patients had 2.49 (95% CI 2.29 to 2.70) times the rate of emergency readmission, 0.60 (95% CI 0.53 to 0.68) times the rate of planned readmission and 2.57 (95% CI 2.41 to 2.73) times the rate of A&E visits compared with housed patients. The 12-month risk of emergency readmission was higher for homeless patients (61%, 95% CI 59% to 64%) than housed patients (33%, 95% CI 30% to 36%); and the risk of planned readmission was lower for homeless patients (17%, 95% CI 14% to 19%) than for housed patients (30%, 95% CI 28% to 32%). While the risk of emergency readmission varied with the reason for admission for housed patients, for example being higher for admissions due to cancers than for those due to accidents, the risk was high across all causes for homeless patients. CONCLUSIONS Hospital patients experiencing homelessness have high rates of emergency readmission that are not explained by health. This highlights the need for discharge arrangements that address their health, housing and social care needs.
Collapse
Affiliation(s)
- Dan Lewer
- Institute of Health Informatics, University College London, London, UK
- Collaborative Centre for Inclusion Health, University College London, London, UK
- Institute of Epidemiology and Health Care, University College London, London, UK
| | - Dee Menezes
- Institute of Health Informatics, University College London, London, UK
| | - Michelle Cornes
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
| | - Ruth M Blackburn
- Institute of Health Informatics, University College London, London, UK
| | - Richard Byng
- Community and Primary Care Research Group, University of Plymouth, Plymouth, UK
| | - Michael Clark
- Care Policy and Evaluation Centre, The London School of Economics and Political Science, London, UK
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
- Alan Turing Institute, British Library, London, UK
| | - Hannah Evans
- Institute of Health Informatics, University College London, London, UK
| | - James Fuller
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
| | | | - Alan Kilmister
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
| | | | - Jill Manthorpe
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Alistair Story
- Find & Treat, University College London Hospitals NHS Foundation Trust, London, UK
| | - Michela Tinelli
- Care Policy and Evaluation Centre, The London School of Economics and Political Science, London, UK
| | - Martin Whiteford
- Department of Nursing & Community Health, Glasgow Caledonian University, Glasgow, UK
| | - Fatima Wurie
- Institute of Epidemiology and Health Care, University College London, London, UK
| | - Alexei Yavlinsky
- Institute of Health Informatics, University College London, London, UK
| | - Andrew Hayward
- Collaborative Centre for Inclusion Health, University College London, London, UK
- Institute of Epidemiology and Health Care, University College London, London, UK
| | - Robert Aldridge
- Institute of Health Informatics, University College London, London, UK
| |
Collapse
|
8
|
Clark M, Cornes M, Whiteford M, Aldridge R, Biswell E, Byng R, Foster G, Fuller JS, Hayward A, Hewett N, Kilminster A, Manthorpe J, Neale J, Tinelli M. Homelessness and integrated care: an application of integrated care knowledge to understanding services for wicked issues. JICA 2021. [DOI: 10.1108/jica-03-2021-0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PurposePeople 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/approachThe 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.FindingsSupporting 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/implicationsThe 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 implicationsIntegration 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 implicationsAddressing 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/valueThis paper examines an application of integrated care knowledge to a key complex, or wicked policy issue.
Collapse
|
9
|
Armstrong M, Shulman C, Hudson B, Brophy N, Daley J, Hewett N, Stone P. The benefits and challenges of embedding specialist palliative care teams within homeless hostels to enhance support and learning: Perspectives from palliative care teams and hostel staff. Palliat Med 2021; 35:1202-1214. [PMID: 33775172 PMCID: PMC8189002 DOI: 10.1177/02692163211006318] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND People residing in UK homeless hostels experience extremely high rates of multi-morbidity, frailty and age-related conditions at a young age. However, they seldom receive palliative care with the burden of support falling to hostel staff. AIM To evaluate a model embedding palliative specialists, trained as 'homelessness champions', into hostels for two half-days a month to provide support to staff and residents and facilitate a multidisciplinary approach to care. DESIGN An exploratory qualitative design. SETTING/PARTICIPANTS Four homeless hostels in London, UK, including nine hostel managers/support staff and seven palliative care specialists (five nurses and two social workers). RESULTS Benefits to introducing the model included: developing partnership working between hostel staff and palliative care specialists, developing a holistic palliative ethos within the hostels and improving how hostel staff seek support and connect with local external services. Challenges to implementation included limited time and resources, and barriers related to primary care. CONCLUSION This is the first evaluation of embedding palliative care specialists within homeless hostels. Inequity in health and social care access was highlighted with evidence of benefit of this additional support for both hostel staff and residents. Considering COVID-19, future research should explore remote ways of working including providing in-reach support to homelessness services from a range of services and organisations.
Collapse
Affiliation(s)
- Megan Armstrong
- Pathway Charity, London, UK.,Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Caroline Shulman
- Pathway Charity, London, UK.,Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | | | | | | | | | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| |
Collapse
|
10
|
Field H, Hudson B, Hewett N, Khan Z. Secondary care usage and characteristics of hospital inpatients referred to a UK homeless health team: a retrospective service evaluation. BMC Health Serv Res 2019; 19:857. [PMID: 31752857 PMCID: PMC6868755 DOI: 10.1186/s12913-019-4620-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/03/2019] [Indexed: 11/16/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Hannah Field
- Royal Surrey County Hospital, Egerton Road, Guildford, GU2 7XX, UK. .,Pathway, 250 Euston Road, London, NW1 2PG, UK.
| | - Briony Hudson
- Pathway, 250 Euston Road, London, NW1 2PG, UK.,Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | | | - Zana Khan
- Pathway, 250 Euston Road, London, NW1 2PG, UK.,UCL Collaborative centre for inclusion health, Department of Primary Care and Population Health, University College London, London, UK
| |
Collapse
|
11
|
Aldridge RW, Menezes D, Lewer D, Cornes M, Evans H, Blackburn RM, Byng R, Clark M, Denaxas S, Fuller J, Hewett N, Kilmister A, Luchenski S, Manthorpe J, McKee M, Neale J, Story A, Tinelli M, Whiteford M, Wurie F, Hayward A. Causes of death among homeless people: a population-based cross-sectional study of linked hospitalisation and mortality data in England. Wellcome Open Res 2019; 4:49. [PMID: 30984881 PMCID: PMC6449792 DOI: 10.12688/wellcomeopenres.15151.1] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Homelessness has increased by 165% since 2010 in England, with evidence from many settings that those affected experience high levels of mortality. In this paper we examine the contribution of different causes of death to overall mortality in homeless people recently admitted to hospitals in England with specialist integrated homeless health and care (SIHHC) schemes. Methods: We undertook an analysis of linked hospital admission records and mortality data for people attending any one of 17 SIHHC schemes between 1st November 2013 and 30th November 2016. Our primary outcome was death, which we analysed in subgroups of 10th version international classification of disease (ICD-10) specific deaths; and deaths from amenable causes. We compared our results to a sample of people living in areas of high social deprivation (IMD5 group). Results: We collected data on 3,882 individual homeless hospital admissions that were linked to 600 deaths. The median age of death was 51.6 years (interquartile range 42.7-60.2) for SIHHC and 71.5 for the IMD5 (60.67-79.0). The top three underlying causes of death by ICD-10 chapter in the SIHHC group were external causes of death (21.7%; 130/600), cancer (19.0%; 114/600) and digestive disease (19.0%; 114/600). The percentage of deaths due to an amenable cause after age and sex weighting was 30.2% in the homeless SIHHC group (181/600) compared to 23.0% in the IMD5 group (578/2,512). Conclusion: Nearly one in three homeless deaths were due to causes amenable to timely and effective health care. The high burden of amenable deaths highlights the extreme health harms of homelessness and the need for greater emphasis on prevention of homelessness and early healthcare interventions.
Collapse
Affiliation(s)
- Robert W Aldridge
- Public Health Data Science, Institute of Health Informatics, University College London, London, NW1 2DA, UK
- Collaborative Centre for Inclusion Health, Institute of Epidemiology & Health Care, University College London, London, NW1 2DA, UK
| | - Dee Menezes
- Public Health Data Science, Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Dan Lewer
- Public Health Data Science, Institute of Health Informatics, University College London, London, NW1 2DA, UK
- Collaborative Centre for Inclusion Health, Institute of Epidemiology & Health Care, University College London, London, NW1 2DA, UK
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE1 1UL, UK
| | - Michelle Cornes
- Health and Social Care Workforce Research Unit, King's College London, London, SE1 1UL, UK
| | - Hannah Evans
- Public Health Data Science, Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Ruth M Blackburn
- Public Health Data Science, Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - Richard Byng
- Community and Primary Care Research Group, University of Plymouth, Plymouth, Devon, PL6 8BX, UK
| | - Michael Clark
- Personal Social Services Research Unit, London School of Economics, London, WC2A 2AE, UK
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, NW1 2DA, UK
| | - James Fuller
- NIHR Health and Social Care Workforce Research Unit, King's College London, London, SE1 1UL, UK
| | - Nigel Hewett
- Pathway Charity, Pathway Charity, London, NW1 2PG, UK
| | - Alan Kilmister
- Health and Social Care Workforce Research Unit, King's College London, London, SE1 1UL, UK
| | - Serena Luchenski
- Collaborative Centre for Inclusion Health, Institute of Epidemiology & Health Care, University College London, London, NW1 2DA, UK
| | - Jill Manthorpe
- Health and Social Care Workforce Research Unit, King's College London, London, SE1 1UL, UK
| | - Martin McKee
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, SE1 1UL, UK
| | - Alistair Story
- Collaborative Centre for Inclusion Health, Institute of Epidemiology & Health Care, University College London, London, NW1 2DA, UK
- Tropical and Infectious Diseases, University College London Hospitals NHS Trust, London, NW1 2PG, UK
| | - Michela Tinelli
- Personal Social Services Research Unit, London School of Economics, London, WC2A 2AE, UK
| | - Martin Whiteford
- Health Services Research, University of Liverpool, Liverpool, L69 3BX, UK
| | | | - Andrew Hayward
- Collaborative Centre for Inclusion Health, Institute of Epidemiology & Health Care, University College London, London, NW1 2DA, UK
| |
Collapse
|
12
|
Luchenski SA, Fitzpatrick S, Hewett N, Aldridge RW, Hayward AC. Can deinstitutionalisation contribute to exclusion? - Authors' reply. Lancet 2018; 391:2210-2211. [PMID: 29893220 DOI: 10.1016/s0140-6736(18)30755-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 03/19/2018] [Indexed: 11/23/2022]
Affiliation(s)
- Serena April Luchenski
- The Farr Institute of Health Informatics Research, University College London, London NW1 2DA, UK.
| | - Suzanne Fitzpatrick
- Institute for Social Policy, Housing and Equalities Research, Heriot-Watt University, Edinburgh, UK
| | | | - Robert W Aldridge
- The Farr Institute of Health Informatics Research, University College London, London NW1 2DA, UK; Centre for Public Health Data Science, Institute of Health Informatics, University College London, London NW1 2DA, UK
| | - Andrew C Hayward
- The Farr Institute of Health Informatics Research, University College London, London NW1 2DA, UK; Centre for Public Health Data Science, Institute of Health Informatics, University College London, London NW1 2DA, UK; Institute of Epidemiology and Health Care, University College London, London NW1 2DA, UK
| |
Collapse
|
13
|
Cornes M, Whiteford M, Manthorpe J, Neale J, Byng R, Hewett N, Clark M, Kilmister A, Fuller J, Aldridge R, Tinelli M. Improving hospital discharge arrangements for people who are homeless: A realist synthesis of the intermediate care literature. Health Soc Care Community 2018; 26:e345-e359. [PMID: 28730744 DOI: 10.1111/hsc.12474] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/19/2017] [Indexed: 06/07/2023]
Abstract
This review presents a realist synthesis of "what works and why" in intermediate care for people who are homeless. The overall aim was to update an earlier synthesis of intermediate care by capturing new evidence from a recent UK government funding initiative (the "Homeless Hospital Discharge Fund"). The initiative made resources available to the charitable sector to enable partnership working with the National Health Service (NHS) in order to improve hospital discharge arrangements for people who are homeless. The synthesis adopted the RAMESES guidelines and reporting standards. Electronic searches were carried out for peer-reviewed articles published in English from 2000 to 2016. Local evaluations and the grey literature were also included. The inclusion criteria was that articles and reports should describe "interventions" that encompassed most of the key characteristics of intermediate care as previously defined in the academic literature. Searches yielded 47 articles and reports. Most of these originated in the UK or the USA and fell within the realist quality rating of "thick description". The synthesis involved using this new evidence to interrogate the utility of earlier programme theories. Overall, the results confirmed the importance of (i) collaborative care planning, (ii) reablement and (iii) integrated working as key to effective intermediate care delivery. However, the additional evidence drawn from the field of homelessness highlighted the potential for some theory refinements. First, that "psychologically informed" approaches to relationship building may be necessary to ensure that service users are meaningfully engaged in collaborative care planning and second, that integrated working could be managed differently so that people are not "handed over" at the point at which the intermediate care episode ends. This was theorised as key to ensuring that ongoing care arrangements do not break down and that gains are not lost to the person or the system vis-à-vis the prevention of readmission to hospital.
Collapse
Affiliation(s)
- Michelle Cornes
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Martin Whiteford
- Health Services Research, University of Liverpool, Liverpool, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, King's College London, London, UK
| | - Richard Byng
- Clinical Trials and Health Research, University of Plymouth, Plymouth, UK
| | - Nigel Hewett
- Pathway, University College Hospital Homeless Team, London, UK
| | - Michael Clark
- The London School of Economics & Political Science, London, UK
| | - Alan Kilmister
- Social Care Workforce Research Unit, King's College London, London, UK
| | - James Fuller
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Robert Aldridge
- Public Health Informatics, University College London, London, UK
| | - Michela Tinelli
- The London School of Economics & Political Science, London, UK
| |
Collapse
|
14
|
Luchenski S, Maguire N, Aldridge RW, Hayward A, Story A, Perri P, Withers J, Clint S, Fitzpatrick S, Hewett N. What works in inclusion health: overview of effective interventions for marginalised and excluded populations. Lancet 2018; 391:266-280. [PMID: 29137868 DOI: 10.1016/s0140-6736(17)31959-1] [Citation(s) in RCA: 196] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 06/16/2017] [Accepted: 07/05/2017] [Indexed: 12/28/2022]
Abstract
Inclusion health is a service, research, and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and excluded populations. We did an evidence synthesis of health and social interventions for inclusion health target populations, including people with experiences of homelessness, drug use, imprisonment, and sex work. These populations often have multiple overlapping risk factors and extreme levels of morbidity and mortality. We identified numerous interventions to improve physical and mental health, and substance use; however, evidence is scarce for structural interventions, including housing, employment, and legal support that can prevent exclusion and promote recovery. Dedicated resources and better collaboration with the affected populations are needed to realise the benefits of existing interventions. Research must inform the benefits of early intervention and implementation of policies to address the upstream causes of exclusion, such as adverse childhood experiences and poverty.
Collapse
Affiliation(s)
- Serena Luchenski
- Centre for Public Health Data Science, Institute of Health Informatics, University College London, London, UK; The Farr Institute of Health Informatics Research, University College London, London, UK.
| | - Nick Maguire
- Department of Psychology, University of Southampton, Southampton, UK
| | - Robert W Aldridge
- Centre for Public Health Data Science, Institute of Health Informatics, University College London, London, UK; The Farr Institute of Health Informatics Research, University College London, London, UK
| | - Andrew Hayward
- Centre for Public Health Data Science, Institute of Health Informatics, University College London, London, UK; The Farr Institute of Health Informatics Research, University College London, London, UK; Institute of Epidemiology and Health Care, University College London, London, UK
| | - Alistair Story
- Find and Treat Service, University College London Hospitals, London, UK
| | - Patrick Perri
- Center for Inclusion Health, Allegheny Health Network, Pittsburgh, PA, USA; Street Medicine Institute, Ingomar, PA, USA
| | | | | | - Suzanne Fitzpatrick
- Institute for Social Policy, Housing and Equalities Research, Heriot-Watt University, Edinburgh, UK
| | | |
Collapse
|
15
|
Shulman C, Hudson BF, Low J, Hewett N, Daley J, Kennedy P, Davis S, Brophy N, Howard D, Vivat B, Stone P. End-of-life care for homeless people: A qualitative analysis exploring the challenges to access and provision of palliative care. Palliat Med 2018; 32:36-45. [PMID: 28672115 PMCID: PMC5758927 DOI: 10.1177/0269216317717101] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Being homeless or vulnerably housed is associated with death at a young age, frequently related to medical problems complicated by drug or alcohol dependence. Homeless people experience high symptom burden at the end of life, yet palliative care service use is limited. AIM To explore the views and experiences of current and formerly homeless people, frontline homelessness staff (from hostels, day centres and outreach teams) and health- and social-care providers, regarding challenges to supporting homeless people with advanced ill health, and to make suggestions for improving care. DESIGN Thematic analysis of data collected using focus groups and interviews. PARTICIPANTS Single homeless people ( n = 28), formerly homeless people ( n = 10), health- and social-care providers ( n = 48), hostel staff ( n = 30) and outreach staff ( n = 10). RESULTS This research documents growing concern that many homeless people are dying in unsupported, unacceptable situations. It highlights the complexities of identifying who is palliative and lack of appropriate places of care for people who are homeless with high support needs, particularly in combination with substance misuse issues. CONCLUSION Due to the lack of alternatives, homeless people with advanced ill health often remain in hostels. Conflict between the recovery-focused nature of many services and the realities of health and illness for often young homeless people result in a lack of person-centred care. Greater multidisciplinary working, extended in-reach into hostels from health and social services and training for all professional groups along with more access to appropriate supported accommodation are required to improve care for homeless people with advanced ill health.
Collapse
Affiliation(s)
- Caroline Shulman
- Pathway Charity, London, UK
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- King’s Health Partners, King’s College Hospital, London, UK
| | - Briony F Hudson
- Pathway Charity, London, UK
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Joseph Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | | | | | | | - Sarah Davis
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | | | - Diana Howard
- Coordinate My Care, The Royal Marsden NHS Foundation Trust, London, UK
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| |
Collapse
|
16
|
Blackburn RM, Hayward A, Cornes M, McKee M, Lewer D, Whiteford M, Menezes D, Luchenski S, Story A, Denaxas S, Tinelli M, Wurie FB, Byng R, Clark MC, Fuller J, Gabbay M, Hewett N, Kilmister A, Manthorpe J, Neale J, Aldridge RW. Outcomes of specialist discharge coordination and intermediate care schemes for patients who are homeless: analysis protocol for a population-based historical cohort. BMJ Open 2017; 7:e019282. [PMID: 29247113 PMCID: PMC5736042 DOI: 10.1136/bmjopen-2017-019282] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION People who are homeless often experience poor hospital discharge arrangements, reflecting ongoing care and housing needs. Specialist integrated homeless health and care provision (SIHHC) schemes have been developed and implemented to facilitate the safe and timely discharge of homeless patients from hospital. Our study aims to investigate the health outcomes of patients who were homeless and seen by a selection of SIHHC services. METHODS AND ANALYSIS Our study will employ a historical population-based cohort in England. We will examine health outcomes among three groups of adults: (1) homeless patients seen by specialist discharge schemes during their hospital admission; (2) homeless patients not seen by a specialist scheme and (3) admitted patients who live in deprived neighbourhoods and were not recorded as being homeless. Primary outcomes will be: time from discharge to next hospital inpatient admission; time from discharge to next accident and emergency attendance and 28-day emergency readmission. Outcome data will be generated through linkage to hospital admissions data (Hospital Episode Statistics) and mortality data for November 2013 to November 2016. Multivariable regression will be used to model the relationship between the study comparison groups and each of the outcomes. ETHICS AND DISSEMINATION Approval has been obtained from the National Health Service (NHS) Confidentiality Advisory Group (reference 16/CAG/0021) to undertake this work using unconsented identifiable data. Health Research Authority Research Ethics approval (REC 16/EE/0018) has been obtained in addition to local research and development approvals for data collection at NHS sites. We will feedback the results of our study to our advisory group of people who have lived experience of homelessness and seek their suggestions on ways to improve or take this work further for their benefit. We will disseminate our findings to SIHHC schemes through a series of regional workshops.
Collapse
Affiliation(s)
- Ruth M Blackburn
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Andrew Hayward
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Michelle Cornes
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Martin McKee
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London, London, UK
| | - Dan Lewer
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Martin Whiteford
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Dee Menezes
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Serena Luchenski
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | | | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Michela Tinelli
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science, London, UK
| | - Fatima B Wurie
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Richard Byng
- Community and Primary Care Research Group, Plymouth University Peninsula Schools of Medicine and Dentistry, PLYMOUTH, UK
| | - Michael C Clark
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science, London, UK
| | - James Fuller
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Mark Gabbay
- Department of Health Services Research, University of Liverpool, Liverpool, UK
| | | | - Alan Kilmister
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Jill Manthorpe
- Social Care Workforce Research Unit, King's College London, London, UK
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Robert W Aldridge
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| |
Collapse
|
17
|
Hewett N. What works to improve the health of the multiply excluded? SOCIAL DETERMINANTS OF HEALTH 2017. [DOI: 10.46692/9781447336860.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
18
|
Hudson BF, Shulman C, Low J, Hewett N, Daley J, Davis S, Brophy N, Howard D, Vivat B, Kennedy P, Stone P. Challenges to discussing palliative care with people experiencing homelessness: a qualitative study. BMJ Open 2017; 7:e017502. [PMID: 29183927 PMCID: PMC5719327 DOI: 10.1136/bmjopen-2017-017502] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To explore the views and experiences of people who are homeless and those supporting them regarding conversations and approaches to palliative care SETTING: Data were collected between October 2015 and October 2016 in homeless hostels and day centres and with staff from primary and secondary healthcare providers and social care services from three London boroughs. PARTICIPANTS People experiencing homelessness (n=28), formerly homeless people (n=10), health and social care providers (n=48), hostel staff (n=30) and outreach staff (n=10). METHODS: In this qualitative descriptive study, participants were recruited to interviews and focus groups across three London boroughs. Views and experiences of end-of-life care were explored with people with personal experience of homelessness, health and social care professionals and hostel and outreach staff. Saturation was reached when no new themes emerged from discussions. RESULTS 28 focus groups and 10 individual interviews were conducted. Participants highlighted that conversations exploring future care preferences and palliative care with people experiencing homelessness are rare. Themes identified as challenges to such conversations included attitudes to death; the recovery focused nature of services for people experiencing homelessness; uncertainty regarding prognosis and place of care; and fear of negative impact. CONCLUSIONS This research highlights the need for a different approach to supporting people who are homeless and are experiencing advanced ill health, one that incorporates uncertainty and promotes well-being, dignity and choice. We propose parallel planning and mapping as a way of working with uncertainty. We acknowledge that these approaches will not always be straightforward, nor will they be suitable for everyone, yet moving the focus of conversations about the future away from death and dying, towards the present and the future may facilitate conversations and enable the wishes of people who are homeless to be known and explored.
Collapse
Affiliation(s)
- Briony F Hudson
- Pathway, London, UK
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | - Caroline Shulman
- Pathway, London, UK
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
- Kings Health Partners, Kings College Hospital, London, UK
| | - Joseph Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | | | | | - Sarah Davis
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | | | - Diana Howard
- Coordinate My Care, The Royal Marsden NHS Foundation Trust, London, UK
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | | | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| |
Collapse
|
19
|
Luchenski S, Clint S, Aldridge R, Hayward A, Maguire N, Story A, Hewett N. Involving People with Lived Experience of Homelessness in Electronic Health Records Research. Int J Popul Data Sci 2017. [PMCID: PMC9351025 DOI: 10.23889/ijpds.v1i1.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
20
|
|
21
|
Michael A, Kadappu K, Shah V, Hewett N, Chow J, Rajaratnam R. Cardiac Outreach Program in Heart Failure-Impacts and Outcomes. Heart Lung Circ 2016. [DOI: 10.1016/j.hlc.2016.06.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
22
|
Affiliation(s)
- Ryan Meili
- Divison of Social Accountability, University of Saskatchewan, Saskatoon, S7N 5E5, Canada
| | - Nigel Hewett
- Pathway Project, University College London Hospitals, London NW1 2BU, UK
| |
Collapse
|
23
|
Hewett N, Buchman P, Musariri J, Sargeant C, Johnson P, Abeysekera K, Grant L, Oliver EA, Eleftheriades C, McCormick B, Halligan A, Marlin N, Kerry S, Foster GR. Randomised controlled trial of GP-led in-hospital management of homeless people ('Pathway'). Clin Med (Lond) 2016; 16:223-9. [PMID: 27251910 PMCID: PMC5922699 DOI: 10.7861/clinmedicine.16-3-223] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Homeless people have complex problems. GP enhanced care (Pathway) has shown benefits. We performed a randomised, -parallel arm trial at two large inner city hospitals. Inpatient homeless adults were randomly allocated to either standard care (all management by the hospital-based clinical team) or enhanced care with input from a homeless care team. The hospital data system provided healthcare usage information, and we used questionnaires to assess quality of life. 206 patients were allocated to enhanced care and 204 to usual care. Length of stay (up to 90 days after admission) did not differ between groups (standard care 14.0 days, enhanced care 13.3 days). Average reattendance at the emergency department within a year was 5.8 visits in the standard care group and 4.8 visits with enhanced care, but this decrease was not significant. -Quality of life scores after discharge (in 108 patients) improved with enhanced care (EQ-5D-5L score increased by 0.12 [95% CI 0.032 to 0.22] compared wtih 0.03 [-0.1 to 0.15; p=0.076] with standard care). The proportion of people sleeping on the streets after discharge was 14.6% in the standard care arm and 3.8% in the enhanced care arm (p=0.034). The quality-of-life cost per quality-adjusted life-year was £26,000. The Pathway approach doesn't alter length of stay but improves quality of life and reduces street -homelessness.
Collapse
Affiliation(s)
- Nigel Hewett
- Medical Director Pathway, University College Hospital Homeless Team, London, UK
| | | | - Jeflyn Musariri
- Barts Health NHS Trust, London, UK, and Division of Medical Education, Brighton and Sussex Medical School, Brighton, UK
| | | | - Penny Johnson
- Brighton and Sussex University Hospital, Brighton, UK
| | | | | | | | - Christopher Eleftheriades
- Centre for Health Service Economics and Organisation, Department of Primary Care, University of Oxford, Oxford, UK
| | - Barry McCormick
- Centre for Health Service Economics and Organisation, Department of Primary Care, University of Oxford, Oxford, UK
| | - Aidan Halligan
- Pathway, RIP, Central Manchester University Hospitals NHS Trust and University of Manchester, Manchester, UK
| | - Nadine Marlin
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Sally Kerry
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | | |
Collapse
|
24
|
|
25
|
|
26
|
Affiliation(s)
- Nigel Hewett
- Discharge Lounge, University College Hospital, London NW1 2BU, UK.
| | | | | |
Collapse
|
27
|
|
28
|
Gray J, Hewett N, Hiley A. Hepatitis B vaccination. Br J Gen Pract 2004; 54:704. [PMID: 15353063 PMCID: PMC1326076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
|
29
|
Hewett N. Homelessness. In from the cold. Health Serv J 1998; 108:30-1. [PMID: 10187501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
A multidisciplinary team formed in January to help rough sleepers in Leicester has found accommodation for half the clients considered. The average age of clients is 35, and three-quarters are male. The initiative has built on existing joint working partnerships in Leicester.
Collapse
|