Delivering integrated health and social care services for people experiencing homelessness

Why are integrated services needed?

Across all forms of health care needs, both physical and mental, people experiencing homelessness report poorer diagnoses and greater barriers to accessing healthcare support than the general population, as evidenced in the Unhealthy State of Homelessness report.

The number of people with a mental health diagnosis increased substantially from 45% in 2014 to 82% in the 2018 – 2021 research cohort, while 63% of respondents from this cohort reported they had a long-term illness, disability or infirmity.

The average age of death of someone experiencing homelessness is around 30 years lower than that of the general population.

What is this resource?

In 2022 the National Institute for Health and Care Excellence (NICE) published guidelines on how to deliver integrated health and social care services for people experiencing homelessness (NG214). They aimed to improve access to and engagement with health and social care, and ensure care is coordinated across different services.

In response, a series of six case studies exploring services that exemplify best practice in delivering the NICE guidelines have been developed by the Homeless Health Consortium (HHC). The case studies illustrate how collaboration across the health and homelessness sectors can effectively reduce health inequalities.

These cases studies will be useful for anyone interested in homelessness and health and reducing health inequalities. This includes homelessness service leaders or staff aiming to improve partnership working and adopt best practice locally and health services seeking to learn from the experience of others.

Which services are featured?

The six case studies showcase a wide variety of services working in homelessness and health:

1. An intermediate care service in the South of England​ - with dozens of step-down and step-up out-of-hospital beds delivering support to people at risk of street discharge for up to six weeks. The service hosts a Social Worker, Psychologist, Occupational Therapist, Housing Officer and Support Workers, with oversight and coordination from a programme manager. Peer support workers with experience of homelessness are an integrated part of the service delivery.
2. An infectious disease outreach team in London​ - delivering assertive diagnosis and treatment for people experiencing homelessness rather than expecting them to attend a service or pre-planned appointment. The focus on infectious disease in many ways helps to open a door to support with biosocial health risk factors such as housing, addiction and welfare, through which the team can promote treatment adherence and increase resilience against future infections.
3. A charity leading innovation in rough sleeping data monitoring in London​ - involving a detailed live database of people sleeping rough in the borough, with case data fed in weekly by local partners. Enabled by a strong history of partnership working between the local authority, health teams and other homelessness providers across the borough, the project allows for in-depth analysis of trends and changes locally, and enables the wider system to adapt delivery to more accurately adapt to needs locally.
4. A nurse-led hospital discharge team in the North of England​ - designed to support safe discharge, reduce unscheduled A&E presentations, reduce stigma and maximise the benefit of a hospital admission as a chance to support people towards recovery. The team follow up with clients after 2 and 6 weeks to ensure discharge plans are working and prevent readmission. They are spread across the hospital and community.
5. A specialist primary care service for people experiencing homelessness in London​ - aiming to operate as a one-stop shop for homeless health, with a multi-disciplinary model that includes nurses, counsellors, a mental health nurse, a psychiatrist, GPs, a podiatrist, and physiotherapy clinics. Emerging local needs means they now also run a specialist Roma clinic.
6. An inclusion health unit within an ICB in the North of England – which aims to achieve high quality healthcare for inclusion health populations, through collaboration, promoting equitable access, experience, and outcomes across the integrated care system footprint. The unit works to better understand and meet health needs, ensuring joint resources are used effectively by planning and delivering together, and sharing learning between places.

Inspirational models

The case studies show what is possible in services that commit to delivering the NICE Guidelines. Looking across this set, the common factors for success include:

• Strong leadership and vision, which was unanimous across all six services. They were each spearheaded by strong senior management with a clear vision and the willingness to champion that cause to anybody who would listen.
• Diversity of experience including interdisciplinary teams and staff with lived experience integrated throughout their services. There were some particularly strong examples of peer involvement where former patients were encouraged to get involved with developing and delivering services.
• Strong support from stakeholders with buy-in at local level, from commissioners, health boards, social care teams and other charities, the services we spoke held relationships and partnerships at their core.

Despite being unified around the key principles of the NICE Guidelines, the six services included here were diverse in both purpose and delivery. While learning from the case studies is transferable across the country, the services themselves are not box-ready – instead, they each flexed to needs in their local area and capitalised on the existing homelessness ecosystem in each setting.