Arch Health CIC Step Down Beds: Case Study

Arch Healthcare - Step Down Beds Service - Case study:

To ensure people who have been admitted to hospital and are at risk of homelessness at the time of discharge have a safe place to recover with regular clinical input Arch has collaborated with local services to provide seven step down beds in the Brighton and Hove. This service has been in place from February 2021. The first year (pilot year) was funded through the Covid Recovery Fund this was then continued through the Out of Hospital Care fund. Currently, for the year 2023/24 the service is funded by Sussex ICB and the Rough Sleepers Initiative (RSI) (BHCC)

The Step Down Beds service is a link between community and hospital services - providing patients experiencing homelessness who are discharged from hospital with accommodation in a supportive hostel, daily clinical visits, and dedicated support workers to ensure they can recover fully after a hospital admission. It can also support patients to stay within the community and receive care and treatment, in order to prevent a hospital admission.

The service is a partnership project and brings together the different skills and expertise of homelessness and inclusion health in the city to provide an integrated and accessible service for those facing homelessness before, during or after a hospital stay. This joined up working enables a holistic approach to inclusion health. The expertise and roles of the partnership are laid out below:

• Provide clinical inreach team, this is a nurse led team with support from GP’s.

• Clinical team visit every day Mon-Fri to monitor existing conditions, change dressings, manage and prescribe medication and refer into other support services (such as substance misuse and mental health)

• Ensure Step-Down resident is registered with Arch GP surgery

• Able to support patients to link in with other primary and secondary care services.

• Manage the accommodation where the beds are located

• Provide Personal Assistants who are responsible for supporting patients while they are in stepdown beds, for example supporting to attend appointments, providing companionship, helping with benefits, advocating.

• Support patients to access food, cleaning and laundry services.

• Manage move on plans

• Identify people within the hospital, carry out initial assessment and start housing process

• Refer into step-down beds

• Ensure safe travel to step down beds

• Works with clients in step down beds to find suitable move on accommodation.

• Project commissioning and reporting

• Identifies move on accommodation

• Lower rates of unplanned hospital admissions and lower rates of unscheduled care (e.g. going to A&E, and getting admitted to hospital).

• Enabling access to detox and rehab and accessing substance misuse services

• Stabilising physical and mental health

• Residents have stabilised with the input from clinical and non-clinical staff

• Improved health engagement, including GP registration, accessing dentists, sexual health clinics, specialist services for diabetes and secondary care teams.

• Supporting patients to better manage medications.

• Moving on to permanent accommodation

• Moving on to employment

• Ensuring daily clinical input has not only improved the health of residents but helped to build engagement with health services.

• Personal Assistants for all step-down residents has been key in building relationships and enabling residents to stabilise.

• Links between the hospital and community teams strengthen through regular meetings and communication.

• Finding suitable accommodation to move on to has been a challenge, it has improved by building better relationships with the city council, creating more than one pathway for residents and having a dedicated Move On Coordinator for residents but it is still taking a long time to find accommodation.

• Taking the time to build good relationships between services, including regular team meetings and sharing knowledge has been key to the success of this service.

The Step-Down Beds service has secured funding for another year in Brighton and Hove, it is hoped that it will continue beyond this.

During the year ahead we are looking at:

• Continuing to develop pathways into suitable move on accommodation.

• Developing initial assessments for health and looking at the patients wider health needs during their stay in step down.

• Building stronger links with other services

• Developing plans to maintain the service beyond 2024.