Title: Effectiveness and Cost-effectiveness of ‘Usual Care’ Versus ‘Specialist Integrated Care’: A Comparative Study of Hospital Discharge Arrangements for Homeless People in England
Funder: Department of Health and Social Care

Abstract: The overall aim of this two year study is to establish firstly the ways in which specialist integrated homeless health and care (SIHHC) services are being developed and implemented to facilitate hospital discharge in England and, secondly, the impact this is having on quality of care and organisational outcomes such as the prevention of readmission to hospital. The study will evaluate the principal models of SIHHC developed as part of the DH's Section 64 (voluntary sector led) ‘ten million pound cash boost’ (DH, 2013) to improve hospital discharge for homeless people, alongside some of the more longer established (clinically led) approaches such as the Pathway model. The main purpose of the study is not to make recommendations as regard one particular model being more effective than the other, but to understand the different components of each model in terms of what works to secure safe, timely and compassionate hospital discharge. In terms of what is already known about SIHHC, it is recognised that there is a fine balance between promoting access by providing specialist services and creating the conditions for further marginalisation and reinforcement of stereotypes. In some areas it is possible that a well developed hospital discharge protocol is able to secure timely discharge for homeless people without the need for SIHHC. To enable exploration of this, hospitals with access to SIHHC will also be compared to those without access to such schemes. This is an important consideration as a key implication of the Francis (2013) inquiry into the abuse and neglect at Mid Staffordshire NHS Foundation Trust is that commissioners and managers will need to pay close attention to the scope for challenge and innovation in routine ‘standard care’. By educating hospital staff about the needs of homeless people, SIHHC may be a means of achieving this but little is know about its effectiveness in this area. Following a literature review, in-depth fieldwork employing realistic evaluation will be carried out in six case study sites across England. Reflecting the principal typological approaches, sites will be purposively selected to include hospitals that have access to clinically led models of SIHHC (n=2), those that have access to housing link worker schemes with no clinical in-put (n=2) and those which rely on standard provision (n=2). In selecting case studies, particular attention will be paid to different aspirations for integration encompassed in service specifications and discharge protocols, showing in the final analysis if and how this impacts on a wide range of outcomes. In each site, fieldwork will comprise: interviews with commissioners and service managers from SIHHC and a range of other agencies ([minimum] n=5 per site); interviews with discharge coordinators, case managers and key workers from SIHHC and a range of other agencies ([minimum] n=5 per site); and interviews with service users (n=10 per site) shortly after discharge from hospital and at three months follow-up. In addition to capturing information on service use, the interviews with service users will ascertain experiences of the hospital discharge process, if ‘joined-up’ care was delivered and overall reflections on the health and well-being outcomes that have been achieved.This qualitative data will then be complimented with more quantitative evidence on the costs and outcomes of specialist discharge schemes (extending the number of sites to 20).

Lay abstract: This study will explore the special services that have been set-up to improve homeless people’s experiences of leaving hospital. It will investigate four different types of specialist service. Some services might for example, put patients in touch with a GP who is specially trained to work with homeless people and who will start to work with them while they are still in hospital. Other schemes might employ a housing support worker to make sure homeless people do not return to living on the streets after being in hospital. We want to know what homeless people think of these specialist services and how they help them to tackle the full range of problems they might have. We also want to know if this specialist support prevents homeless people from having to go back into hospital. To see how well these schemes are working and how much they cost we will also study hospital discharge in two hospitals where there is no specialist support for homeless people.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE